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our results suggest that body shape trajectories are a good indicator of body weight trajectories and may be used when cohort studies are not possible keywords body shape body weight changes body weight trajectory birth weight sociodemographic factors background body weight trajectory is defined as changes in weight over life and one way to evaluate it is the use of silhouette scales a set of figures representing the body from very lean to very heavy 1 using the silhouettes chosen by individuals to represent their bodies at previous ages and using appropriate analysis it is possible to determine selfperceived body shape trajectory 2 3 4 5 the latter can be used as a proxy for body weight trajectory because silhouettes scales have high correlation with body mass index and they work well to identify obesity and underweight in the brazilian adult and older adult population 67 sociodemographic variables are important for explaining weight changes low educational level can negatively influence the opportunities for good employment and contribute to low family income in this scenario racial inequalities play a major role in brazil since blacks brazilian earn lower average incomes than whites which can be explained by lower schooling occupation of less prestigious job positions and racial discrimination 8 meanwhile low family income affects place of residence offering less access to safe and suitable locations for leisuretime physical exercise and healthy food outlets as well as limiting the family funds available for food 9 10 11 physical activity and healthy eating are wellestablished strategies for individual weight control and obesity prevention 1213 early life is a critical period for development some exposures in the first 1000 days impact child development and can favour excess weight 14 in this context low maternal education is a major factor related to insufficient prenatal care and excess gestational weight gain 1516 which in turn affect foetal and infant health women with more schooling are presumably more likely to care for themselves have more knowledge about selfcare and enjoy higher socioeconomic status 15 as described above poor socioeconomic conditions can limit access to nutritionally balanced food including during pregnancy which affects the infant´s birth weight birth weight is an indicator of nutritional sufficiency during gestation and is related to the child´s subsequent weight status studies have observed that higher birth weight is associated with higher odds of excess weight in childhood 17 and that low birth weight is associated with increased odds of childhood obesity and underweight 18 children with obesity are also more likely to present preobesity or obesity in adulthood 1920 individuals with body shape trajectories characterized by a marked increase in weight or maintenance of large body size across their lifespan may be more prone to develop chronic diseases in adulthood or older age 3 4 5 in this context identifying factors related to these trajectories is essential for encouraging the development of preventive public health strategies until this moment we have not identified any studies that have evaluated body weight trajectories using silhouette scales to identify changes in weight within a brazilian population additionally we have not found any studies conducted with brazilian and other populations that have assessed factors associated with body shape trajectories the current study thus aimed to evaluate body shape trajectories from 5 to 40 years of age and verify associations between them and birth weight current bmi and sociodemographic conditions in participants in the longitudinal study of adult health the present study will contribute to the current scientific literature on body shape trajectories by utilizing a novel method to assess changes in weight across the lifespan within a brazilian population this method enables the evaluation of weight changes even in the absence of cohort studies in addition this study has the potential to encourage the development of public policies aimed at promoting changes in modifiable factors associated with body shape trajectories that are related to negative health outcomes methods study population elsabrasil is a multicentre cohort study that began in 20082010 with 15105 civil servants from 35 to 74 years of age affiliated with six public institutions in the northeast south and southeast regions of brazil participants answered facetoface questionnaires on sociodemographic aspects healthrelated habits and behaviours medical history and mental health and underwent clinical examinations additional information on this cohort is available in a previous publication 21 the current study is a crosssectional analysis that used data from the first followup wave of elsabrasil which was conducted 38 years after the baseline with 14014 participants 7657 women and 6357 men at 38 to 79 years of age we excluded participants with age less than 40 years because the selected scale for body shape trajectories follows participants until this those who failed to answer the body shape scale and those who only answered one question leaving a total of 13674 individuals in the multiple correspondence analysis we excluded participants that declared their race as indigenous or asiandescendant due to the small numbers of participants in these categories and those with missing data for any of the study variables resulting a total of 10960 participants body shape trajectory assessment participants were asked to identify their body shapes at 5 10 20 30 and 40 years of age by choosing one of the nine silhouettes developed by stunkard sorensen and schulsinger 1 in the first follow up wave the instruments validity for measuring past shapes was assessed by must willett and dietz and it was considered satisfactory 22 for quality control we assessed the stability of the silhouettes chosen by a sample consisting of 204 participants who responded to the body shape perception form administered during the first followup of the elsabrasil study the sample size was determined for all research centres of the elsabrasil study with a significance level of 5 quotas were established based on age categories and occupational categories to ensure that the selected sample was representative of the entire cohort population an interval of 7 to 14 days was adopted between the test and the retest the stability was considered good and very good based on the cutoff points established by byrt 23 with values ranging from 068 to 079 for women and 063 to 083 for men considering all the body shapes selected in the test and retest birth weight bmi and sociodemographic conditions birth weight was selfreported by participants with the following question according to the information you have what was your birth weight below 25 kg 25 kg to 4 kg or over 4 kg birth weight less than 25 kg was defined as low from 25 to 4 kg as adequate and greater than 4 kg as high to determine bmi weight was measured with a digital scale accurate to 50 g and height was measured with a fixed stadiometer accurate to 01 cm according to the protocol proposed by lohman roche and martorell 24 bmi cutoff points were 249 kgm 2 for underweight and normal range 249 to 299 kgm 2 for preobesity and ≥ 30 kgm 2 for obesity 12 sociodemographic variables were age sex selfreported race participant´s education maternal education and monthly per capita family income the income categories were defined based on terciles using the 2013 exchange rate to convert brazilian reais to us dollars the values for the lowincome set at up to 795 for women and up to 675 for men the middleincome range was defined as 795 to 1446 for women and 675 to 1374 for men while the highincome category included amounts higher than 1446 for women and higher than 1374 for men we selected the birth weight race and maternal education variables because they precede body shape trajectories and may potentially explain their development as they are associated with weight status 152526 we also chose participants education and per capita family income because despite being variables related to the current stage of life they are social determinants that influence health behaviors associated with weight status such as diet and physical activity 26 additionally we included the current bmi in the analyses because if the bmi categories align with body shape at 40 years it will corroborate with silhouette scales are a suitable tool for evaluating body shape trajectories in a brazilian population statistical analysis we employed a clustering method for longitudinal data to identify body shape trajectories from 5 to 40 years of age cluster analysis is a statistical technique employed to create distinct and nonoverlapping subgroups of individuals or objects based on shared characteristics 27 the cluster method used in this study is based on a variation of the kmeans algorithms and group trajectories according to their shapes using a distance measure that respects the form and a mean that respects the form 2 data simplification was used because the study population was large the algorithm summarizes the total population in a smaller group of individuals when a data simplification procedure is used the trajectories of the smaller groups are called senators because they represent the entire population senators are selected via classical kmeans 2 we tested 100 and 200 senators because when we attempted to increase this number some iterations in the analyses failed to converge the results were similar using both senators numbers so we present the results using 100 senators in this study after data simplification the clustering method chose the centres of the clusters by random selection and allocated participants to one of the trajectories for which they showed similar shapes subsequently the average trajectories were plotted the trajectories were named according to their depiction with silhouettes 12 defined as lean 34 as medium shape and 59 as heavy 28 theoretically the nine potential body shape trajectories are stable shape increasing body shape and decreasing body shape we thus tested clusters with three to nine trajectories we defined the number of body shape trajectories that best represented males and females using the generalized fréchet distance matrix between the respective trajectory clusters and selected the number of clusters with the highest mean generalized fréchet distance the associations between body shape trajectory and birth weight maternal education per capita household income race participant´s education and bmi were assessed by multiple correspondence analysis and these variables were described using absolute and relative frequencies mca is an exploratory technique utilized to assess relationships or correspondence between categories of qualitative variables this analysis visually illustrates the relationship between a set of variables where the proximity of categories in space indicates a correspondence between them 29 one advantageous aspect of mca is that it does not assume any assumption concerning probability distributions thus allowing the investigation of different patterns of association including nonlinear the analysis provides total inertia and the resulting square root corresponds to the total variance explained by each dimension 30 the number of dimensions was chosen by analysing the decline in eigenvalues using scree plot dendrograms were performed with the coordinates obtained in the mca to determine the clusters providing clear visualization of the categories of variables in each group 31 scatterplots were formed by the coordinates of each category in each dimension and clusters of categories were used to identify factors associated with body shape trajectories the scatterplot´s xaxis and yaxis represent the data´s variability explained by the first and second dimensions the dots represent each variable category the groups of associated variables categories were delineated by lines a previous study with participants in elsabrasil found that body image differed between men and women men tended to underestimate and not distort their body size while women tended to overestimate their body size 32 the way individuals perceive their bodies can impact selfperceived body shape trajectories so we stratified the analyses by sex we attempted to stratify the analysis of body shape trajectories by age group but since the trajectories were similar between the two age groups we ultimately decided only to stratify the analyses by sex the r software version 405 33 and the libraries kmlshape ca factoextra dendextend and ggplot2 were used we set the significance level at 5 results body shape trajectory according to the highest mean of generalized fréchet distance the number of trajectories from 5 to 40 years of age was three for men and four or five for women four versus five body shape trajectories for women produced similar results so we chose five trajectories to represent the female population approximately 11 of women and 33 of men had a leanwithmarkedlyincreasing body shape trajectory in which they started lean and gained weight markedly until reaching a heavy body shape meanwhile 4 of women and 16 of men showed a heavystable trajectory characterized by maintenance of heavy body shape in women 18 showed a mediumstable trajectory characterized by maintaining medium body shape throughout life while 14 showed a leanstable trajectory marked by maintenance of lean shape throughout life and 53 showed a leanmoderatelyincreasing trajectory in which they started lean and gained weight until reaching medium body shape most men showed a leanslightlyincreasing trajectory in which they began lean at five years of age and gained weight until reaching medium shape multiple correspondence analysis in the population included in multiple correspondence analysis mean age was 55 years for women and men most of the participants reported their race as white and maternal schooling as primary or less the majority of both sexes had university degrees were preobese and reported adequate birth weight the mca plot allowed identification of five groups in women associations between variable categories and groups formation can be evaluated by analysing the proximity between points the first dimension explained 751 of the data´s variability and the second explained 65 considering the contributions of each variable category in the composition of each dimension we observed that the second dimension was primarily formed by heavystable body shape trajectory adequate and high birth weight the other categories were important in forming dimension one maternal education primary or less adequate and low birth weight brown race middle per capita family income and preobesity were associated with leanmoderatelyincreasing body shape trajectory white race maternal education equivalent to secondary school or university high per capita family income and participant´s education equivalent to university were associated with the mediumstable trajectory obesity and high birth weight were associated with heavystable and leanmarkedlyincreasing trajectories and normal bmi was associated with the leanstable trajectory the mca plot allowed identification of four groups in men the first dimension explained 737 of the data´s variability and the second explained 83 the second dimension was primarily formed by leanmarkedlyincreasing and leanslightlyincreasing body shape trajectories adequate birth weight bmi normal range and obesity the other categories were important in forming dimension one table 1 mean of the generalized fréchet distance among the trajectories according to this measure the ideal number of body shape trajectories to represent the male population was three and four or five for the female population white race maternal education equivalent to complete secondary school or university high and middle per capita family income participant´s education equivalent to university preobesity and adequate birth weight were associated with the leanmarkedlyincreasing body shape trajectory maternal schooling primary or less brown race low birth weight and normal range bmi were associated with the leanslightlyincreasing trajectory obesity and high birth weight were associated with the heavystable trajectory two cluster groups were not associated with any body shape trajectory including participant´s secondary schooling or less low per capita family income and black race trajectory number mean of the generalized fréchet distance women men discussion the study´s objective was to evaluate body shape trajectories from 5 to 40 years of age and verify associations between them and birth weight current bmi and sociodemographic conditions in participants in the elsabrasil study we found five body shape trajectories for women and three for men low birth weight was associated with a slight increase in shape among men and a moderate increase in shape among women high birth weight was associated with worse body shape trajectories in women and men higher sociodemographic status and white race were associated with leanmarkedlyincreasing body shape trajectory in men and mediumstable trajectory in women a study conducted with 11423 spanish participants of both sexes from the seguimiento universidad de navarra cohort found five body shape trajectories from 5 to 40 years for men and women using the same silhouette scales employed in the present study the analysis was not stratified by sex the authors also found the leanmoderate increase and mediumstable trajectories just like in the present study however they found trajectories such as mediummoderate increase heavymedium and heavymoderate increase fig 2 body shape trajectories of women and men participating in the elsabrasil note we use longitudinal cluster data to identify the trajectories which differed from the trajectories found in the present study 28 low birth weight can indicate nutritional insufficiency during pregnancy and in the present study it was associated with lower maternal schooling brown race and leanmoderatelyincreasing body shape trajectory in women and leanslightlyincreasing trajectory in men for pregnant women to have access to quality food in sufficient quantity they need favourable financial conditions if the study participants mothers have lower schooling they probably tended to hold poorer paid jobs impacting food´s availability and affordability during the pregnancy exposure to food deprivation during the pregnancy may result in subsequent accumulation of adipose tissue when food availability is restored predisposing to obesity throughout life 34 thus nutrient shortage during gestation may have promoted adaptive responses during foetal development resulting in moderate and slight weight gain across women´s and men´s lives previous studies found an association between high birth weight and excess weight at different moments in the life cycle including childhood adolescence and adulthood 35 in the present study high birth weight was also associated with maintenance of heavy body shape across life in both sexes and a marked weight increase across women´s lives since childhood and adolescence are critical periods of development excess weight in these stages affects weight status in subsequent life stages including increased likelihood of preobesity or obesity in adulthood 1920 individuals that maintained a heavy body shape and those with a marked increase in weight across life had higher risk of hypertension 3 excessive daytime sleepiness 36 vascular ageing 37 diabetes mellitus 38 and allcause and cardiovascular mortality 4 when compared to those who maintained medium or lean body shape across life as expected obesity was associated with a heavystable body shape trajectory in both men and women and a leanmarkedlyincreasing trajectory in women preobesity was associated with a leanmoderatelyincreasing trajectory in women and leanmarkedlyincreasing trajectory in men normal bmi was associated with a leanstable trajectory in women and leanslightlyincreasing trajectory in men the results reflect consistency between current weight status and body shapes at 40 years and corroborate that the silhouette scale can be a useful tool for assessing body shape trajectories the highest categories of maternal education per capita family income and participant´s education besides white race were associated with the mediumstable trajectory in women in contrast among men the same sociodemographic conditions were associated with poor body shape trajectory characterized by a marked increase in body shape across life reaching obesity at 40 years old these results can be explained by gender differences in eating patterns the quantity and quality of food consumed is a gender marker studies show that women tend to eat more healthily than men which includes higher consumption of fruits and vegetables and lower consumption of fatty meats meat products and alcohol in addition women receive greater pressure from society to maintain a slim body which can make them worry about their diet and practice physical activity for weight management and maintenance of adequate weight 3940 although black race low per capita family income and secondary schooling or less were not associated with any body shape trajectory these categories were associated with each other this result corroborates findings in the brazilian population data published by the brazilian institute of geography and statistics 41 in 2020 showed racial segregation in the labour market before the covid19 pandemic most brown and black brazilians worked at occupations that required less schooling and that provided lower income on the other hand most white brazilians worked in higherpaid occupations that required higher education the current study has some limitations body shape trajectories depend on the participants perception of their own bodies and are susceptible to distortions which may overestimate or underestimate the body shape thus the results may not represent participants true body weight trajectories however considering the high cost and difficulty of conducting longitudinal studies that follow individuals from childhood into adulthood we believe the assessment of body shape trajectories can help elucidate the implications of weight changes across life multiple correspondence analysis represents the researchers view of specific issues so other researchers may not consider the same variables and different results can be obtained the birth weight and maternal education information were selfreported so there may have been a misclassification despite the abovementioned limitations our study was the first to show the contribution by birth weight and sociodemographic variables to perceived weight changes over time we stratified the analyses by sex considering that perceived body image is different for men and women with men tending to underestimate and not distort their body size while women tend to overestimate their body size 32 furthermore the satisfactory stability of the body sizes chosen by the participants to indicate previous body sizes strengthens the results obtained in the trajectory analysis and contributes to expanding the assessment of the psychometric quality of the silhouette scales used we use a clustering method for longitudinal data that respects the form of trajectories to group the individuals this technique also allows defining the body shape trajectories of individuals who do not have all time points evaluated avoiding many exclusions and thus the use of imputation methods 2 childhood and adolescence are critical periods of development as they involve the consolidation of lifestyle and behavioural patterns the adoption of unhealthy habits and behaviours often influenced by peers or family can lead to nutritional inadequacies during this life stage and have longterm implications for health obese children and adolescents are at a higher risk of developing obesity in adulthood 4243 so we believe that these stages of life have a greater influence on the determination of body shape trajectories current literature has shown that exposure to adverse situations in childhood and adolescence such as physical emotional verbal and sexual abuse household substance abuse mental illness domestic violence emotional psychological parental separation or divorce household criminality neglect bullying and serious illness or injury is associated with negative longterm health outcomes such as overweight or obesity 44 however these conditions were not evaluated in the present study because these variables were not available in the elsabrasil study it is suggested that future research assess how these adverse experiences in childhood and adolescence can influence the development of different body shape trajectories across the lifespan additionally as we have not identified studies that have assessed the association between body shape trajectories and health outcomes in the brazilian population such as the development of chronic diseases and mortality we suggest that future studies investigate these associations understanding how different body shape trajectories are related to health outcomes can provide important information for the prevention and management of longterm health conditions conclusions the variables described in the literature as associated with worse weight status in specific life moments were also associated with worse body shape trajectories in this scenario we think silhouette scales can be used to define changes in weight across life mainly when conducting cohort studies is not possible public policies that promote antenatal care and improvements in sociodemographic conditions can positively impact body shape trajectories funding the elsabrasil study was supported by the brazilian ministry of health and the brazilian ministry of science technology and innovation the brazilian innovation agencyfinep and 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 evaluating lifelong weight trajectories is challenging due to the high costs of studies that follow individuals from childhood to adulthood the use of silhouette scales has been a new approach to assess the body shape trajectory across life as a proxy for body weight trajectory depending on body shape trajectories individuals may be more prone to develop diseases in adulthood therefore identifying factors related to them is essential for public health this study aimed to evaluate body shape trajectories across the lifespan and to verify associations between them birth weight body mass index and sociodemographic conditions in a brazilian cohort methods this is a crosssectional analysis conducted with 14014 participants of first followup data collection of longitudinal study of adult health elsabrasil elsabrasil is a multicentric prospective cohort study initiated in 2008 with civil servants of six public institutions in the northeast south and southeast regions of brazil we applied a clustering method to longitudinal data to identify body shape trajectories from 5 to 40 years of age and assessed the associations between these trajectories and birth weight body mass index and sociodemographic conditions race education maternal education and monthly per capita family income using multiple correspondence analysiswe found five body shape trajectories for women and three for men low birth weight was associated with a slight to moderate increase in shape high birth weight was associated with maintaining large body size in both sexes and markedly increased body shape in women higher sociodemographic status and white race were associated with marked increases in body shape in men and maintenance of medium body shape in womenthe study shows that variables related to worse lifetime weight status evaluated by anthropometry such as presence of obesity are also associated with worse body shape trajectories as assessed with silhouette scales

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introduction for the most part previous research on the relationship between partnership status and health has shown that living with a partner is associated with better health outcomes when measured in terms of mortality or morbidity furthermore some of these studies have uncovered that partnership could determine mortality differentials to a larger extent than socioeconomic status in some circumstances three main mechanisms behind partnership have been emphasized as contributing to explain its health benefits the reduction of risky behaviors and unhealthy habits the development of a support network that can buffer the effect of poor health episodes and the increase in material wellbeing associated with economies of scale resulting from the addition of resources of both partners and the possibility of task specialization these processes do not influence males and females identically first the benefits appear to be greater and manifest more quickly among males that is to say mens health improves shortly after the beginning of a union whereas its effects on womens health occur more gradually secondly women appear to benefit principally from the increase in material wellbeing whereas males mainly benefit from the cessation or moderation of risky behaviors and unhealthy habits in contrast other partnership situations as well as the transitions between them have been associated with negative effects on health as exemplified by the increases in depressive symptoms and or chronic morbidity among men and women who either experienced a separation or divorce or became widows in addition those engaged in subsequent unions after an episode of separation did not completely recover the original advantage they once had in terms of health however the health benefits of partnership among mature and older adults have been questioned some studies explain this result as the effect of survival selection a major source of heterogeneity within populations which causes unexpected pattern of a given phenomenon as a function of age survival selection may originate on contextual andor individual levels contextually it is associated with the living conditions of the population which strongly determine mortality levels throughout the life course and particularly in childhood for instance current populations that were exposed to hard living conditions and highmortality levels at preadult ages are more likely to be selected in terms of survival accordingly these populations might exhibit better or less disadvantaged than expected health outcomes at old ages than populations with better living conditions and lower mortality levels at the individual level survival selection may be determined by a number of behavioral socioeconomic andor genetic factors for instance if singleness is associated with risky health behaviors then it is expected that singles suffer from higher mortality levels and thus become a more selected segment of the population when reaching old age this work aims to explore the association between health and partnership in adulthood comparing individuals who entered into their first union and those who remained single at mature ages biographical information on health status and partnership status provided by europeans aged 50 and over in the sharelife survey is utilized for this purpose all 13 countries included in this survey were analyzed both jointly and specifically these countries represent different mortality backgrounds associated with diverse contexts of living conditions for the cohorts that are analyzed in this study which indirectly permit us to approach the influence of survival selection effects between these populations another potential source of heterogeneity at the individual level is partly controlled by utilizing their health status in childhood differences between these populations were also noticeable with regard to the intensity and the timing of some key aspects of the second demographic transition that took place from northwestern to southeastern regions mainly during the second half of the twentieth century sdt proposes that changes in a number of demographicrelated behaviors are associated not only with socioeconomic variables but also with largescale changes in values the spread of these values differs across countries and is related to both cultural and legislative aspects which are important to understand the crossnational partnershiprelated differentials observed among europeans aged 50 and older surveyed by sharelife methods data microdata from the survey of health ageing and retirement in europe were utilized share is a crossnational panel survey conducted on individuals aged 50 and over the third wave of share was held between the autumn of 2008 and the summer of 2009 and it included retrospective questions that permit a lifecycle approach to certain issues such as health and partnership trajectories the initial sample size of interviewees aged 50 and their partners was slightly reduced after discarding proxies and excluding missing cases of any of the variables involved in the analysis and individuals who experienced an event of poor health before turning 30 valid cases amounted to 89 overall ranging from 84 to 94 the distribution of cases according to age group and sex prior to and after the data screening remained largely unchanged the retrospective analysis of health and partnership spanned working ages to avoid the potential biases related to changes in socioeconomic status after retirement the lower age boundary in this analysis responds to the aim of avoiding the effect of age to mediate the relationship between partnership status and health at the age of 30 825 of individuals were already in a partnership status other than single and this percentage rises slightly to 901 at the age of 64 individuals younger than 64 at the time of the interview were rightcensored in the analysis study variables the health outcome represents whether the individual experienced a distinct period during which your health was poor compared to the rest of your life over adulthood and in the case of an affirmative answer when this period occurred the prevalence of this event was 335 among men and 371 among women germany displayed the highest prevalence and greece the lowest prevalence overall in approximately 74 of the cases this event occurred between the ages of 30 and 64 as with other selfreported health indicators this item captures both the objective and subjective dimensions of health which maintain a solid association for the most part therefore it approaches the health status of individuals in a more comprehensive manner than more specific health indicators this indicator also shows a significant relationship with other subjective health indicators such as the current selfperceived health status at the time of the survey that said it must be acknowledged that what constitutes a distinct period of poor health may differ from individual to individual as well as from country to country partnership history for each interviewee between the ages of 30 and 64 was reconstructed from retrospective questions that recorded the occurrence of unions separations and widowhood technically this information was stored in a timevarying variable that was categorized as follows • single • first union • interruption of the relationship • widowhood • second or higher rank union the timevarying approach to partnership status as practiced in this study prevents the artifact of the attenuated effects of marital status on morbidity and mortality as rendall et al proposed in 2011 the first unions at the time of the interview were clearly prevalent in all the countries under analysis but significant differences between countries were observed for the other partnership situations southern european countries together with poland showed the lowest percentage of breakdowns whereas nordic countries showed the highest percentages for these situations as expected a lower percentage of widowers with respect to widows was also found with regard to this the main difference between countries was found among widows ranging from 156 to 297 age at the time of the interview was collapsed into four groups 5059 6069 7079 and 80 and over this variable controlled for two possible sources of bias in the time of the occurrence of the event of interest namely a choice set bias in that longer life increases the number of potential episodes of poor health and consequently forced the individual to prioritize health to a greater extent than younger individuals and a recall bias in that longer life may worsen the ability to remember and report past events precisely for instance it might be the case that older individuals prioritized more recent episodes thus resulting in an artifact of postponement of poor health episodes childhood health was included to control for individual infirmity in our analyses through the question would you say that your health during your childhood was in general excellent very good good fair or poor andor not 1 among other problems a more specific set of items in this survey likely underestimates the periods or episodes of poor health with respect to the indicator that was chosen for this work for example the prevalence of a period of poor health is 21 using hs054 whereas the value is 404 when gl009 is used this necessarily has to do with the different wording and different conceptual nature of both items moreover any period of poor health in hs054 can be embodied by several illnesses which provokes a problem of ambiguity in the use of specific illnesses as health indicators therefore we believe that gl009 is a better technical choice for our purposes and its figures are more trustworthy taking into account that sharelife focuses on the population aged 50 and over nevertheless specific comments in the discussion section are devoted to deal with the implications of this choice in our results constant these answers were grouped into two categories good health and poor health working status asked retrospectively about the changes in a persons labor situation throughout adulthood which was also treated as a timevarying variable in our analyses education has two purposes in the analyses to approach the socioeconomic status of individuals together with their working status and to approach differences in health risk behaviors educational levels across countries were harmonized using the international standard classification of education by unesco and the resulting variable grouped some categories to obtain more robust crosstabulations for all countries first level of education includes no studies completed and primary studies or first stage of basic education second level of education second stage of basic education and secondary education and third level of education postsecondary and all possible levels of tertiary education sex menwomen age in our models was a timevarying variable that ranged from the age of 30 to the age of 64 or alternatively the age at time of the interview each individual was observed as many times as the years passed until the event occurred or until the age of 64 in the absence of an event age squared was included in the models to better fit with age effects beyond a linear function of age to ease the interpretation of our results the analyzed countries were grouped according to their infant mortality rates during a decade of the interwar period for which data are available for all countries 1 high mortality includes countries with infant mortality rates above 100 per thousand at the beginning of the period and mostly remained so over the period these countries are poland the czech republic2 spain italy and greece3 2 intermediate mortality austria belgium france germany and denmark 3 low mortality sweden switzerland and the netherlands accordingly this group represents the lowest level of potential survival selection at a contextual level analysis first a descriptive analysis displays the percentage of interviewees that experienced the event of poor health across the range of ages studied in this analysis the countries are sorted according to the mortality levels defined above second survival analysis was utilized to measure the risk of suffering from a distinct episode of poor health as a function of the partnership status and controlling for the abovementioned variables this analysis was performed through discretetime hazard models because the variables involved in the analysis were interval censored control variables were entered into the models as timevarying covariates and timeconstant covariates two different model specifications are presented and discussed first a pooled model was run to capture the net differences in the hazard of poor health among countries as well as to test the hypothesis of the attenuation or reversion of a firstunion advantage at mature and older ages second countryspecific models explored the existence of patterns of partnershiprelated determinants of poor health hazard across countries the coefficients displayed report the relative difference with respect to the reference group whereby positive values indicate a higher hazard than the reference category and vice versa only statistically significant coefficients are commented and discussed in detail results table 1 displays that women exhibit a higher prevalence of experiencing the event of poor health during the 3064 age range particularly in switzerland sweden and spain there are three exceptions to this pattern austria germany and the netherlands in addition younger groups at the time of the interview display a higher prevalence which for the most part peaks at ages 6069 whereas it bottoms out among individuals aged 80 and over likewise the prevalence of poor health is invariably higher among individuals that reported poor or unstable health during their childhoods finally by contrast education does not make any significant difference in most of the countries analyzed once other variables are controlled for table 2 displays the hazard coefficients whereby countryspecific differences are controlled for in a pooled model in this specification the netherlands was taken as the reference country because it exhibited the lowest infant mortality rate during the 19271938 period 4eight of the twelve countries show a higher hazard of poor health compared to the netherlands all four countries with lower hazards belong to the high infant mortality group whereas only one of the five countries so categorized shows a relatively higher hazard of poor health with respect to the netherlands looking at partnership status categories when countryspecific differences were controlled for none showed a lower hazard of poor health than singleness indeed two of them displayed significantly higher hazards poor or unstable health at preadult ages clearly increases the risk of suffering from poor health during adulthood in addition most of the sociodemographic covariates included in the analysis displayed significant effects the hazard of poor health increases significantly with age although the assumption of linearity is refuted by the significant coefficient of the age squared whereas the age at the time of the interview displays the opposite effect in that being interviewed at older ages likely reduces the probability of prioritizing a single distinct event of poor health within the range of ages 3064 those who did not work between ages 3064 show a higher risk of experiencing poor health education does not display any significant effect when countryspecific differences were controlled for and no significant differences between the hazards experienced by men and women are found the results from countryspecific models support the most substantial part of those provided in the pooled model there is no evidence of health advantages associated with partnership throughout adulthood in these european countries among the individuals who reached the age of 50 in reality spain and france display significant differences in favor of single individuals regarding other partnership situations living in a second or higher rank union as well as a separation or divorce show a similar pattern across countries positive coefficients that are significant in few cases widowhood displays the most heterogeneous effect across countries with significant results only in spain age age squared age at the time of the interview childhood health and working history show homogenous effects within almost all of the countries analyzed and these effects are in accordance with those described in the pooled model finally this model specification helps understand the tenuous and erratic effect of sex and educational level uncovered by the pooled model sex is significant in five countries but while women exhibit a higher hazard of poor health in greece sweden and switzerland the opposite occurs in germany and the netherlands education only shows an effect in greece and the netherlands discussion this study analyzed the hazard of experiencing poor health over adulthood as a function of changes in partnership history and a number of individual sociodemographic characteristics in thirteen european countries the countries represent different paces and pathways into the sdt and they also embody different contexts of living conditions among the cohorts analyzed the latter might imply different levels of potential healthand mortalitydriven selection effects our results demonstrate that in this segment of the european population living in a first union throughout adulthood is not associated with a meaningful advantage compared to those who remained single at least when health is measured by a comprehensive indicator such as the one utilized here this result supplements and enhances previous partial evidence from case studies based on either crosssectional or longitudinal analyses which made use of different health indicators for instance in the urban spanish region of madrid regidor et al found higher survivorship rates among singles aged 65 with respect to those living with a partner goldman et al reached similar conclusions about mortality and disability from a shortterm longitudinal study conducted with a sample of americans aged 70 and over bardage et al also found no difference in terms of selfrated health among married and not married individuals aged 6589 in study comparing sweden the netherlands and spain a number of these studies hypothesized that the absence of the protective effect of partnership on health does not necessarily reflect the net effect of partnership biography on health but rather some degree of selection among individuals that have reached older adult ages this selection may work on two levels individually and contextually on the one hand single individuals suffer from a higher mortality risk and as a consequence those who survive until mature and older ages may represent a more select segment of the population this point was supported through independent hazard models for each age group in which the higher the age group the lower the risk of poor health of single individuals in comparison with those who were in a first union explanations other than the survival selection effect could be proposed but they are not very plausible in our opinion in addition some authors have shown that health influences the probability of individuals to enter into a union the retrospective data from sharelife are insufficient to fully consider reverse causality between partnership status and health even though the interaction between childhood health and partnership status was tested in this analysis without having obtained significant results on the other hand our results also point to some degree of mortalityrelated selection at the country level because four of the five countries categorized as highmortality countries during the first half of the twentieth century show no significant effect or even lower hazards of poor health with respect to the lowmortality reference once individuallevel variables are controlled for however we acknowledge that this is an intuitive interpretation this hypothesis is not supported by the hazard coefficients based on specific illnesses reported in sharelife all types of data whether crosssectional longitudinal or retrospective the latter being the case of this study have proven to be influenced by survival selection when mature and older ages are analyzed as a consequence the true effect of partnership status on health among this specific subpopulation cannot be precisely measured and the likely survival selection should be of concern in all cases when the relationship between any sociodemographic factor and health is addressed only longitudinal data associated with longterm followup can adequately measure the actual magnitude of that selection effect although we applied a survival analysis throughout adulthood in this study the selection of individuals with a better health profile cannot be avoided creating a potential effect on the results this effect is likely to be larger among those segments of the population that are in principle more exposed to healthrelated disadvantages and for longer periods which seems to be the case of single individuals by contrast other partnership situations such as divorce or widowhood are less likely to be affected by the survival selection or its effect is less intense due to a later start or the temporary nature associated with those situations however the influence of these situations on health found in results must be taken with some caution due to the few individuals included in these categories separation or divorce displays a negative effect on health over adulthood and the same is observed among second or higher ranks of unions thus confirming findings from previous research the end of a relationship is stressful enough in itself to have negative consequences on an individuals health in fact poor health status has been shown to be one of the contributing factors for separation in addition it may imply a worsening of economic status which together with the expected consequences of aging may derive a disadvantaged position within the marriage market before an occasional new union that is these individuals become less attractive and less competitive as a function of the factors previously described widowhood is usually associated with increasing socioeconomicrelated vulnerability but in the current study only spain shows a significant health disadvantage associated with widowhood in our opinion several factors might contribute to buffering the potential effect of widowhood on the hazard of poor health the range of ages is retrospectively analyzed that reduces the probabilities of widowhood and the set of provisions from the welfare state that mitigates the negative effect of this episode using sharelife data biro ´ pointed out the complexity of the relationship between widowhood economic restrictions and health with regard to different welfare policies across european countries although individuals working status shows a significant effect on the hazard of poor health it is not possible to hypothesize about the underlying mechanisms because poor health itself is a determinant of working status the control exerted in our models through the information on childhood health status does not solve this problem because no direct causal association between health at childhood and working status during adulthood can be ascertained through our data a similar reasoning applies to the educational level although in this case no significant effect is observed in our results finally it is important to note that no significant differences in the risk of poor health are observed between men and women in eight of the thirteen countries analyzed once the remaining sociodemographic variables are controlled for in the five countries where sex differences are statistically significant they do not point univocally in greece sweden and switzerland there is a lower hazard of poor health among men whereas in germany and the netherlands the opposite is observed this finding is interesting to us because it would invite a supplement and revision to the socalled sex healthsurvival paradox on the basis of retrospective data

the association between health and partnership status is a growing concern within the social sciences some partnership situations exhibit positive effects on health while partnership breakdowns display negative impacts however case studies show that these associations may change with age due to potential sources of heterogeneity within a population the current analysis explored this association over the adult life course ages 3064 of europeans aged 50 years and older based on retrospective information on health and partnership from sharelife n 23535 after data screening the data allowed us to control for sociodemographic covariates as well as for individual infirmity measured by childhood health we also considered contextual survival selection effects by comparing 13 european countries for which preadult mortality levels largely differed among the cohorts involved discretetime hazard analyses examined the risk of suffering from a major episode of poor health selfreported in adulthood as a function of partnership history using two approaches a pooled model and countryspecific models the results revealed no differences between those who lived with a partner first union and single individuals in terms of the retrospective hazards of poor health we hypothesize that this result stems from the cumulative effect of survival selection on individuals in advanced ages according to partnership status the results also partially point to the plausibility of a contextual survival selection which should be confirmed by further research based on additional health indicators

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introduction young adult carers are defined as individuals between 18 and 25 years who provide informal care support or assistance to family members with disability chronic illness mental health issues or substance misuse problems yacs are assumed to carry out substantial caring tasks and to take on a significant level of responsibility the tasks performed may be practical including household tasks emotional care practical support or personal care the age period between late adolescence and midtwenties has been termed emerging adulthood in industrialized countries this may be a prolonged period of exploration without commitment however this may also be a developmental phase where important life choices are made regarding education andor professional career furthermore this is a period for developing a more equal relationship with parents managing financially and establishing emotional independence although many experience emerging adulthood as a period of personal growth increased autonomy and maturity others may experience this as a demanding life phase characterized by uncertainty and challenge emerging adulthood may be a particularly difficult life phase for yacs who need to balance their time between caring and being independent and who need to find ways to fulfill personal social and professional aims without neglecting their care responsibilities family members and others may depend on that the yac prioritizes hisher role as carer it is reasonable to assume that for many yacs it is difficult to manage potentially opposing responsibilities and expectancies lack of largescale surveys makes it difficult to estimate the prevalence of young adults with significant care responsibilities this limits the possibility to predict who among yacs are in need of support and who are coping well as the number of research studies on yacs are limited we lack knowledge on many aspects of the life of these young people a recent european report indicates that we need to know more about ethnicity and financial circumstances for carers below 30 years as few studies have focused on the context of caring we have limited knowledge on specific dimensions or characteristics of the young adult carer population such as gender social class family structure financial situations or ethnicity gender has been examined in some studied with children and adolescent with care responsibilities reporting mixed findings some studies indicate that girls assume more caregiving tasks than boys whereas other studies including both young carers below 18 years and yacs have found higher prevalence of male caregivers evidently more research on the relationship between gender and caring responsibility in yacs is warranted caring for others has been described as rewarding and meaningful bringing positive emotional and psychological benefits for the carer as well as the ill or disabled family member having care responsibility may contribute to the development of practical and emotional skills and is considered to stimulate resilience problemsolving empathy sensitivity and ability to cope with lifechallenges however research with children teenagers and older adults with care responsibilities has shown that there may also be negative outcomes on the mental and physical health of carers besides a few studies on health outcomes for yacs we have limited knowledge about the impact of care responsibilities in this life phase one exception is a study of undergraduate students reporting that young present andor past caregivers showed more symptoms of anxiety and depression than a control group of noncaregivers clinical levels of symptomatology was reported among many of the yacs another study including both young adults below 18 years and yacs reported higher somatization and lower life satisfaction in carers compared to noncaregivers a third study reanalyzing two surveys of samples of 1825 year olds found that most yacs in both samples reported being in excellent very good or good health these diverse findings indicate that we need more knowledge on the impact of caregiving on yacs furthermore to be able to support yacs we need to understand factors that might increase potential negative health outcomes amount of care responsibility may be one important moderator a relationship between level of caregiving and level of psychological stress has been found in a national health study of adults in sweden two studies on yacs found no association between level of caregiving and amount of psychological distress or mental health problems however others have found that youth and young adults with higher amount of caregiving responsibility have poorer mental health outcomes a qualitative study reports that yacs do not have enough time for themselves when balancing their care responsibilities and other commitments this makes it reasonable to assume a relationship between amount of care commitments and health problems in yacs due to the limited number of studies this association needs to be examined further during the last 10 years the norwegian government has taken initiatives to improve services for children and adults who are relatives of patients with physical mental or substance misuse problems eg changes in health legislation have been made and a national guide on how to support next of kin has been developed when parents or children have a chronic illness or substance misuse all public health services are obliged to look after the needs of children in these families in spite of this development the awareness on young family carers is still low and no services are especially targeting young carers or yacs hopefully knowledge on the prevalence characteristics and health problems among yacs may contribute to a larger awareness as well as better services for this group of young adults to sum up our knowledge of caregiving in young adults is limited with regard to prevalence and characteristics of this population as well as potentially negative health outcomes for yacs previous studies have small sample sizes often with an explorative qualitative design in the present study we include a large cohort of students aged 18 to 25 years from a national survey in norway the current study fills a gap in the literature by examining demographic variables as possible predictors of young adults with caring responsibilities for family members or others with physical or mental illness disability or substance misuse as we dont know enough about consequences of caring responsibilities for yacs the study assesses several areas of health problems including internalizing problems sleep problems and somatic complaints as well as a positive measure of life satisfaction as care responsibilities and other commitments in the life of the young adult may be difficult to balance and this may be a possible source of psychological distress we also examine the relationship between the amount of caring responsibilities and health problems among yacs materials and methods procedure the shot2018 study is a national student survey for higher education in norway initiated by the three largest student welfare organizations sammen sit and sio in the shot2018 study data were collected electronically through a webbased platform details of the study have been published elsewhere but in short the shot2018 was conducted between february 6 and april 5 2018 and invited all fulltime norwegian students pursuing higher education to participate in all 162512 students fulfilled these inclusion criteria of whom 50054 students completed the online questionnaires yielding a response rate of 308 as the current study was an investigation of yacs we excluded participants aged 26 years and older yielding a final sample size of 40205 participants aged 1825 years the average time spent answering the questionnaire was 21 min although a few universities and colleges allocated time in school classes allowing the student to complete the survey during a lecture no teachers were instructed to provide support or assistance instruments demographic information all participants indicated their sex and age and participants were also asked about their relationship status as well as their accommodation status finally participants were categorized as an immigrant if either the student or hisher parents were born outside norway exposure variable all students were asked if they had regular care responsibilities for someone with physical or mental illness disabilities or substance misuse if answering yes to this question the students were asked how many hours they spent on a typical weekday and weekend day to help this person the exact phrasing of the questions is detailed in table 1 these were survey questions that have previously been tested for clarity among young carers and their parents outcome variables symptoms of anxiety and depression were assessed using the hopkins symptoms checklist derived from the 90item symptom checklist this is a screening tool designed to detect symptoms of anxiety and depression the scale consists of 25 statements regarding anxiety and depressive symptoms as experienced during the past two weeks with response categories not at all to extremely an investigation of the factor structure of the hscl25 based on the shot2014 data supported an unidimensional model in the student population mean scores were calculated where a higher score indicated a higher level of anxiety and depression in the current study a mean score above 20 on the hscl25 was used as a conservative cutoff to indicate high levels of anxiety andor depression insomnia all participants indicated the number of nights per week they experienced difficulties initiating sleep difficulties maintaining sleep and early morning awakenings as well as daytime sleepiness and tiredness participants were then asked for how long they had suffered from these sleep problems this information was used as an operationalization for insomnia disorder according to the dsm5 criteria further details of the sleep questionnaire used in this cohort have been published elsewhere somaticphysical health was assessed by the somatic symptom scale8 an 8item reliable and valid selfreport measure of somatic symptom burdenhealth complaints cutoff scores identify individuals with low medium high and very high somatic symptom burden as recommended we dichotomized the sss8 using 12 as the cutoff value to indicate the presence of a high or very high somatic symptom burden life satisfaction was assessed by the satisfaction with life scale the swls is a 5item scale designed to measure global cognitive judgments of ones life satisfaction participants indicate how much they agree or disagree with each of the 5 items using a 7point scale that ranges from 7 to 1 statistics ibm spss version 25 for mac was used for all analyses chisquare tests were used to examine possible demographical differences between students with care responsibilities and the control group number of hours spent by female and male students on care responsibilities on weekdays and weekends were also examined chisquare tests were used to investigate the association between hours of care responsibilities and the prevalence of anxiety and depression insomnia and somatic symptom burden and life satisfaction stratified by gender logistic regression analysis were conducted to provide effectsize estimates oddsratios on the same dependent variables stratified by sex the following potential confounders were included in the adjusted analyses age marital status accommodation status divorced parents financial difficulties and immigrant status we also computed estimated marginal means for the three continuous outcomes measures controlling for the same confounders effect sizes were calculated using cohens d formula according to cohens guidelines these effect sizes should be interpreted with ds around 020 representing small effect sizes ds of about 050 moderate effect sizes and ds above 080 large effect sizes the normality of the data was examined using skewness and kurtosis and all continuous measures were well within the recommended ranges there was generally little missing data and hence missing values were handled using listwise deletion as the shot2018 study had several objectives and was not designed to be a study of students with care responsibilities specifically no a priori power calculations were conducted to ensure that the sample size had sufficient statistical power to detect differences in outcomes ethics statement the shot2018 study was approved by the regional committee for medical and health research ethics in norway an electronic informed consent was obtained after the participants had received a detailed introduction to the study results sample characteristics the sample comprised 40205 young adults with a mean age of 22 years in terms of students having care responsibilities for others with physical or mental illness disabilities or substance misuse 64 of female and 34 of male students reported this 55 of the total sample of these the majority reported that they did not live together with the persons they had care responsibilities for as detailed in table 2 having care responsibilities for others was associated with being single having divorced parents and being of nonnorwegian ethnicity students with care responsibilities also reported more financial difficulties than others figure 1 displays the distribution of male and female students with care responsibilities on weekdays and weekends both on weekdays and weekends a significantly larger proportion of female compared to male students spent 2 h or more on care responsibilities correspondingly more male students spent 1 h or less on care responsibilities compared to female students there were also significant differences between weekdays and weekends with both female and male students spending more hours with care responsibilities on weekends than on weekdays care responsibilities and mental health problems mental health problems were significantly associated with amount of care responsibilities in a doseresponse manner as displayed in figure 2 while 301 of female students with no care responsibilities score above the cutoff for moderate symptoms of anxiety and depression the corresponding proportions were 447 and 564 among women spending 1 h or less and 2 h or more per weekday respectively on care responsibilities the same pattern was observed for men with 14 of men with no care responsibilities reporting mental health problems compared to 244 and 314 among men spending 1 h or less and 2 h or more per weekday respectively on care responsibilities as also detailed in figure 2 the magnitude of associations were similar among men and women with no significant gender differences in adjusted ors as displayed in figure 3 a similar pattern was observed when analyzing the hscl25 as a continuous measure compared to individuals with no care responsibilities the observed effect sizes were d 033 and d 054 for 1 h or less and 2 or more hours of care respectively care responsibilities and insomnia insomnia was significantly more prevalent among students with care responsibilities while 322 of female students with no care responsibilities fulfilled the dsmv criteria for an insomnia disorder the prevalence of insomnia was 46 and 537 among women spending 1 h or less and 2 h or more per weekday respectively on care responsibilities insomnia was also more prevalent among men with care responsibilities but the doseresponse relationship observed in women was not found for men as for mental health problems the ors regarding insomnia were comparable in magnitude in both genders except for men spending 2 h of care responsibilities which was lower than for females care responsibilities and somatic symptom burden a similar doseresponse relationship was found between somatic symptom burden and amount of care responsibilities while 211 of female students with no care responsibilities were classified as having a high or very high somatic symptom burden the corresponding proportions were 335 and 465 among women spending 1 h or less and 2 h or more per weekday respectively on care responsibilities the same pattern was observed for men with 9 of men with no care responsibilities reporting a high or very high somatic symptom burden compared to 159 and 245 among men spending 1 h or less and 2 h or more per weekday respectively on care responsibilities no significant differences were observed between men and women regarding the strengths of associations a similar pattern was observed when analyzing the total score of the sss8 compared to individuals with no care responsibilities the observed effect sizes were d 031 and d 061 for 1 h or less and 2 or more hours of care respectively care responsibilities and satisfaction with life an inverse doseresponse relationship was observed between life satisfaction and amount of care responsibilities while 396 of female students with no care responsibilities reported high or very high life satisfaction the corresponding proportions were 295 and 221 among women spending 1 h or less and 2 h or more per weekday respectively on care responsibilities the same pattern was observed for men with 432 of men with no care responsibilities reporting a high or very high life satisfaction compared to 376 and 319 among men spending 1 h or less and 2 h or more per weekday respectively on care responsibilities the adjusted ors were somewhat weaker for men compared to women a similar pattern was observed when analyzing the total score of the swls compared to individuals with no care responsibilities the observed effect sizes were d 019 and d 035 for 1 h or less and 2 or more hours of care respectively discussion in the national student survey 55 of the respondents reported that they had care responsibilities for family members or others with physical or mental illness disabilities or substance misuse caring was associated with being female single having divorced parents being immigrant and having financial difficulties the majority of students with care responsibilities did not live with the person they cared for they spent more time during weekends compared to weekdays on care responsibilities with around 50 both men and women spending 3 h or more on caring responsibilities per day on weekends for both men and women more mental health problems insomnia and somatic symptoms as well as lower satisfaction with life were found among students with care responsibilities compared to students without care responsibilities the number of hours spent on caring was associated with the magnitude of mental health problems insomnia somatic symptoms and satisfaction with life in a doseresponse pattern prevalence and gender differences few largescale surveys provide estimates on prevalence of caregiving among young adults however a study in united kingdom identified 53 of young adults aged 1824 as carers almost identical to the prevalence in the present study furthermore by reviewing estimates of young carers in 7 studies from different european countries leu et al found prevalence rates ranging from 45 to 8 according to the national statistical institute there are about 545 000 young adults between 18 and 25 years in norway with an estimate of 55 yac just below 30 000 young adults on a national level are assumed to care for chronically ill substance misusing or disabled family members or others the prevalence of caregiving in the current study was significantly higher in women compared to men furthermore on average the female students spent more hours on caregiving than male students did similar gender difference has been reported in other age groups of caregivers ie older adults children and adolescents whereas other studies report higher prevalence of male caregivers the mixed findings between studies may be a result of different recruitment strategies samples and measurements it has for example been found that females are more involved in some type of caring activities such as domestic work than others if the findings in the current study are replicated we need to examine why the responsibility for care lay more heavily on young adult women exploring differences in gender roles cultural expectations values and priorities among men and women could contribute to a better understanding of the gender differences in informal caregiving financial stress family structure and migrant families young adult carers reported more financial difficulties compared to other students this is in line with previous findings financial hardship among yacs may be a consequence of low income in families with one or more family member with chronically illness substance misuse or disability however the financial difficulties reported by yacs may also be a result of conflicting demands of combining care responsibilities education and parttime employment for some of yacs there might just not be enough time to take on a parttime job besides studies and care responsibilities higher prevalence of caregiving was found among students from divorced families this finding is in line with previous studies associations between having divorced parents and care responsibility may be understood as a vulnerability in singleparent families in divorced families the young adult may have less choice about becoming a caregiver especially if the single parent is the one who is the carerecipient and if no other healthy parent is present in the family to share the care responsibility our results indicated that more students from immigrant families provide informal care in a report from four european countries on the situation for young ethnic minority carers below 30 years higher prevalence of carers in migrant families is assumed to be the result of several mechanisms migrant families may have lower awareness of how the welfare state works and where to turn for help and may therefore be less likely to access services that support people with a disability or chronic illness they may also have stronger culturally attitudes of shame or stigma associated with disability or mental illness additionally some may have language barriers making it difficult to access the help they need finally there may be higher cultural expectations that care should be provided by family members and the young adults may themselves experience a strong moral obligation to take care of family members in need we have presented demographic characteristics of yacs these suggest that some young adults may be more willing to or perhaps have less choice about taking on care tasks in immigrant families as well as single parent families there may not be sufficient income to pay for external help there may not be others present to provide the care needed there may be no community care or homebased services available or if available it may not be acceptable for family members to receive these services negative health outcomes and amount of care responsibilities in the present study students who confirmed caregiving responsibility had more negative health outcomes compared to noncaregiving students whereas previous studies have found that young carers experience the caring responsibility as rewarding carers in different age groups also report adverse effects in line with increased rate of health problems found among carers in general the negative outcomes among yacs in the present study were evident on several health markers ie anxiety and depressive symptoms sleep problems and somatic symptoms these results should however be understood in the context of the transition period of emerging adulthood it has been suggest that while the lives of noncaregiving emerging adults reach a peak of newfound autonomy and possibility the lives of yacs reach a peak of dismay and isolation increased rates of anxiety and depressive symptoms insomnia and somatic complaints reported by yacs may reflect emotional stress responses of worrying loneliness and guilt related to the role as carer as well as possible shame anxiety and worry associated with the illness substance misuse or disability of the person they are caring for chikhradze et al furthermore yacs may also have emotional reactions due to the caring responsibilities leaving them with limited time for relaxation social life and leisure activities the doseresponse association found between extent of caring and negative health outcomes suggests that the adverse effects of caring increase parallel to the hours invested in looking after the carerecipient according to a previous study yacs become vulnerable when the level of caregiving becomes excessive the negative outcomes observed among yacs may be a result of the pressure of managing education personal relationships and the hours needed to care for the ill or disabled relative however more timeconsuming caring might also be an indicator of how ill or disabled the carerecipient is the amount of social resources available in the family andor the lack of help and support received from health andor social services according to the current study negative health outcomes occur also after the young person has left the family of origin to live elsewhere it is possible that this may be a result of continuing anxiety stress tiredness and physical and emotional strain associated with the caringroles of yacs satisfaction with life and amount of care responsibilities positive outcomes of caring is emphasized in the literature we included satisfaction with life as a positive outcome measure to assess beneficial effects of care responsibility however the results indicate lower life satisfaction in yacs compared to other students furthermore lower life satisfaction was associated with higher number of hours spent on care responsibilities this suggests that life satisfaction may not capture the positive consequences of providing care for someone close probably other measures are needed to capture the characteristics that have been suggested as positive outcomes of caregiving eg increased maturity autonomy sensitivity empathy and life skills strengths and limitations the strengths of the present study include a large study population and psychometrically sound measures the survey questions applied to identify yacs have been thoroughly examined for clarity and assumed to be suitable for identifying young carers the results should be interpreted in accordance to the relatively modest response rate for the survey with little information about the characteristics of nonparticipants beyond age and gender distribution the prevalence estimate of yacs from this study is based on selfreport because young carers are often not identified by professionals in health care education and social services selfreport measures are commonly used and considered the best available strategy to identify this group of cares however no information about or definition of yacs was provided to the responders in the survey we assume that the awareness of the role of young carer is limited among norwegian students this may have made it more difficult for the students to recognize the care responsibility they are providing this would represent a bias toward an underestimation of the prevalence of yacs in the present study young carers may experience barrier against entering higher education eg due to inability to leave the family or the person they care for and insufficient support and guidance at school this may be especially true when it comes to young carers from ethnic minorities thus a selection bias might be present in our sample probably resulting in a lower estimated prevalence of yacs due to this potential selection bias the present results should not be generalized to the whole population of yacs as females constitute about 70 of the student population in norwegian collegesuniversities the gender difference in the sample should not represent a substantial bias in the current study other limitations include the lack of information about the type of care tasks performed whether the young person cares for someone with physical or mental health problems disability or substance misuse and whether the care recipient is a parent a sibling a friend or a partner as the focus of the present study was mainly on negative health consequences possible beneficial effects of the caregiving role beyond life satisfaction were not included this is an important limitation as caregiving has been found to also have positive emotional and psychological benefits for the carer being a crosssectional study we cannot determine the temporal order and causality between caring responsibility and health outcomes however caregiving most likely affects health outcomes rather than the other way around implications young adults who care for ill substance misusing or disabled relatives or others need to be acknowledged and to receive targeted support these young adults are a great resource for family members for the health care system and for society and their willingness to provide care should be recognized and valued lack of practical emotional and financial support may be related to health problems and reduced life opportunities for yacs when family members are chronically ill disabled or substance misusers it is essential that the health consequences of all family members is considered including the situation for the young adults who no longer live in the family household this is increasingly important as the need for informal care is expected to rise in the future due to more outpatient care for patients with chronic illnesses increasing number of single parent households and a growing population of older persons to develop interventions to support yacs and prevent negative health consequences greater awareness among politicians and decision makers in social services community planning and education is warranted our results show that interventions should address ways to reduce the hours needed for yacs to provide care preferably by providing flexible help for families from homebased services as the negative health outcomes are related to hours of caring support that reduce the care responsibility seems to be particularly important this may also make it easier for yacs to achieve their educational goals young adult carers report that they need someone to talk to someone who may offer hope give advice and with whom they can share experiences and coping strategies developing adequate interventions may prevent or moderate negative health consequences among yacs however these need to be delivered with respect and sensitivity to overcome potential barriers of fear shame and loyalty that may make it difficult for many yacs to seek external support conclusion young adult carers in higher education in norway have more negative health problems compared to other students this vulnerability needs to be acknowledged by norwegian authorities and professionals within health care social services and the educational system we need to develop interventions that support yacs who struggle to balance life between caring completing education and fulfilling personal and social aims in addition homebased services should be available for families with chronically ill substance misusing and disabled person the small number of research studies on yacs internationally indicate that there may be limited awareness about the health and educational consequences of caring in many countries the burden of caregiving needs to be considered when investigating health problems among young adult students across countries data availability statement the datasets for this article are not publicly available because of privacy regulations from the norwegian regional committees for medical and health research ethics requests to access the datasets should be directed to bs guidelines for access to shot data are found at approval from rec is a prerequirement ethics statement the studies involving human participants were reviewed and approved by the regional committee for medical and health research ethics in western norway the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

the aim of the present study was to examine prevalence characteristics and health outcomes among young adults 18 to 25 years who provide informal care to family members or others with physical or mental illnesses substance misuse or disabilitiesthe sample was obtained from a national survey in norway from 2018 among students in higher education the shot2018study the current sample comprise 40205 participants 702 women mean age 22 years sd 17 outcome measures participants answered questions on care responsibilities mental health problems the hopkins symptoms checklist25 insomnia sleep questionnaire somatic health somatic symptom scale8 and life satisfaction satisfaction with life scale results 55 of the respondents reported having care responsibilities caring was associated with being female single having divorced parents being an immigrant and having financial difficulties more mental health problems insomnia somatic symptoms and lower life satisfaction were found among respondents with care responsibilities number of hours of caring was associated with negative health outcomes in a doseresponse patternprofessionals within health care social services and the educational system should be sensitized to the needs of young adults with care responsibilities for family members or others with illness substance misuse or disabilities the negative health problems among these young adult carers yacs should be acknowledged and adequate support made available

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introduction social media can significantly impact the information exchanges with its simple fast and powerful cohesion force according to statistics as of june 2017 there were 751 million internet users in china with the overwhelming majority of information obtained by social media 1 the certain advantages of the speed of information dissemination and appeal of social media 2 have brought opportunities for risk communication of disasters for example the red cross received 8 million donations within 48 h after the 2010 haiti earthquake thanks to the relevant blogs and pictures posted through social media 3 the social media has broken the monopoly of traditional news media on information dissemination by letting people create their own online blogs meanwhile as online information is prone to be distorted it has also brought risks to communication on disasters 4 for example some scholars have found in their studies of rumors that the reasons why rumors on common knowledge have been flowing consistently in social media is due to the large number of audiences and the difficulties to refute them 5 in addition the complexity of the causes of manmade disaster has made the official information untrustworthy to the public 6 which led social media become a greater contributor of disaster information it is fair to say that with the publics increasing interest towards social media an extended research on different characteristics of risk communication of disasters must be carried out to enable us to take better advantage of the positive impact of social media on risk communication of disasters while minimizing the negative impact of social media in a timely manner many relevant researches have been carried on this kind of topic king j jones n studied the impact of social media on risk communication from the perspective of interconnected scenario and information dissemination mechanism and found that is the impact of social media is less important than traditional media 7 what is more fema has actively used various social media to provide disaster related information to the public 8 different strength of social relationships formed by different social media has produced different effect for risk communication for example it has been found that while the online relationship in facebook is to some extent based on the offline relationship 9 most relationships formed in twitter weibo etc are oneway asymmetric connections 10 as another example it has been demonstrated by prof granovett that a weak tie denotes a weak relation between individuals which offers more room for the transmission of new information and a variety of resources a strong tie denotes a relationship between individuals with stronger relations which could produce greater redundancy problem in information transmission as well as offer some psychological support such as trust respect and sense of responsibility 11 this is obvious that the communication network formed through social media is a weak relationship network which possesses such characteristics as largescaled diversified etc moreover more information can be acquired through social media 12 it can be said therefore that the social relations as shown from social media network play important roles in risk communication of disasters this study will use the method of social network analysis to study the social relations formed by social media based on the comparative analysis on natural disaster and manmade disaster the impact of the network structure of social media on risk communication of disasters will be discussed moreover the research results will help solve such practical problems as well as some theoretical problems related to risk communication based on social relations materials and methods theoretical framework circulation pattern of information the technical complexity of manmade disaster which causes an asymmetric distribution of disaster information has made it hard for the general public to acquire firsthand information causing the public to find various means to obtain disaster information means such as the official channels social media or oral accounts from friends etc 13 in addition the stigmatization responsibility distribution and other characteristics of manmade disaster 14 can lead to complex interest distributions the formation of different interest groups and antagonistic emotions which has put much emphasize on the role of opinion leaders 15 based on the different characteristics of natural disaster and manmade disaster a disaster information flow pattern in social media has been found as shown in figure 1 in figure 1 s represents the source of information which contains natural and social clues c represents the original subject of the social mediaweibo c a is the subject of a class blogs which includes blogs posted by either governmental or media c b symbolizes the subject of b class blogs which includes blogs of unofficial organizations and individuals o represents the opinion leaders and p is short for the public first of all for risk communication on manmade disaster is influenced greatly by opinion leaders the information was processed and filtered several times for example the hazardous information on chemical facilities can only reach to the public through the path of enterprise examinerhigher government examinergrassroot government examiner to summarize the following characteristics has been found for the manmade disaster to start with the source of information is diverse which enables the information receiversca cb o obtain relevant information through a variety of natural clues and social clues next as the opinion leaders are formed virtually the information feedbacks among core groups ca cb and o are relatively sufficient 16 in addition the guidance of opinion leaders to the subjects of the small groups is reflected by the fact that the opinion leaders can guide to some extent the flowing direction of the mainstream information within their small groups most information that opinion leaders disseminate to the public flows in oneway finally the characteristic differences among different small groups can lead to different opinions within different small groups next unlike manmade disaster there is rarely any conflict among different interest groups within the natural disaster communication groups for instance individuals can communicate directly with each other in a relatively equally and smooth way which tempers opinion conflict and then weakens the role of opinion leaders 17 hence the biggest difference between the information flow of natural disaster and the information flow of manmade disaster lies in the role of opinion leaders as shown in figure 1 in cases of risk communication on natural disaster the lack of antagonistic interests groups has led to a lack of conflicting views as well as corresponding opinion leaders inside small groups on the other hand the information obtained by the public on natural disaster is relatively objective which results in relatively fewer opinion information especially the opposing opinion information the risk communication model based on the above analysis a conceptual model of the impact of social network on risk communication is established as shown in figure 2 the model shows different network characteristics between the social media of two kinds of risk communication of disasters which can impact the effect of risk communication in addition for different network entities the impact can be different depending on the different locations of the opinion leaders or the groups preferences what is more the topic preference of the public can also exert an impact on information dissemination 1819 data source social media covers such social network sites as weibo wechat online social forums and other types of forums in this study certain information in the authoritative sina weibo forum has been selected as the data source according to the statistics as of march 2018 more than 800 million people have registered sina accounts which include more than 175000 governmental accounts as another example more than 100 million pieces of information would be posted through sina every day which covers all aspects of social news and hot topics 20 in addition the threshold for blogs posted through sina is set lowly users can as they like forward all kinds of interested news disseminate knowledge or express their mood through either blogs pictures videos links or other forms of communication moreover the fact that the information can be posted or searched at any place any time has enabled the information flow or exchanged at a faster rate 21 on the one hand to study the impact of social media on risk communication on manmade disaster the explosion in tianjin binhai new area has been selected the accident was an extremely serious production safety liability accident happening on 12 august 2015 which has brought great social impact since the explosion there was a lot of information posted on sina on the accident making the accident a hot topic of weibo therefore this study will use the discussion on tianjin explosion on sina as the research object focusing on the characteristics of social network formed by risk communication on hazardous chemicals in social media the impact of characteristics of social network on risk communication on hazardous chemicals according to the index data of search engine of baidu related information posted through weibo was mainly concentrated in the first half month of the accident therefore the relevant content on sina have been retrieved from 12 august 2015 to 31 august 2015 more specifically an advanced search function provided by sina was used to collect data which has set such key words as tianjin tanggu tianjin port binhai new area explosion fire accident 812 etc after preliminary screening of data data unrelated to the tianjin explosion was manually excluded further as many blogs on the accident were not much forwarded commented or liked yielding no big social impact the research objects would only include those that have at least one date involving more than 1000 individuals finally 562 blogs posted through 396 weibo accounts have been singled out among them 17 were posted through government 185 were posted through news media of weibo 283 were posted through either celebrities or noncelebrities 77 were posted through unofficial organization in weibo in total 417 blogs were posted through certified accounts of weibo and 145 were posted through noncertified accounts on the other hand for the study on the impact of social media on risk communication on natural disaster typhoon pigeon has been selected as a typical study object typhoon pigeon was a natural disaster formed on 20 august 2017 the disaster has brought huge destruction in areas of zhuhai hong kong macao and other other southern china causing 24 deaths and 682 billion worth of us dollars on direct economic losses according to index of baidu search engine relevant information concerning this typhoon was published mainly in the first ten days of typhoon formation therefore the relevant blogs in weibo of this typhoon from 20 august 2017 to 31 august 2017 have been retrieved using similar search method on weibo blogs on tianjin explosion the key words typhoon pigeon pigeon zhuhai typhoon as keywords has been chosen finally 70 weibo blogs posted through 51 weibo accounts were screened out among them 6 were posts of the government 56 were from news media of weibo 3 were created by celebrities or noncelebrities 5 were posted through unofficial organizations in weibo 65 were issued by certified account and 5 were issued by noncertified account research methods the social network analysis method was selected to analyze and create models the forwarding network of weibo has been analyzed to explore the characteristics of social media network the following steps have been used to build the online risk communication on tianjin explosion and typhoon pigeon 22 first of all taking sina hot blogs as an actor a n group which covers all g actors was set up which is recorded as n n 1 n 2 • • • n i • • • n g if there is a relationship between the pair of actors and the relationship is directional the pair can then be thought as an orderly pair n i n j and can be recorded as n i → n j if a forwarding relationship was found between the two sina accounts the two will be considered as orderly pairs with a forwarding direction from one account to the other to record all forwarding relationships of accounts of sina hot blogs as orderly pairs the forwarding adjacency matrices of hot sina blogs were constructed moreover because the matrices are directional they are formed asymmetrically the forwarding adjacency matrices for tianjin explosion and typhoon pigeon were constructed respectively then the forwarding adjacency matrices among sina hot blogs were converted into pajek files further the method of clustering placement was used for visual display that is referring to the nature of the nodes and the connections among them the nodes of the networks were clustered by kamada kawai algorithm hence the forwarding network for hot blogs on tianjin explosion and the forwarding network for hot blogs on typhoon pigeon were constructed the following can be generalized from figure 3 the tianjin explosion network has a relatively obvious coreperiphery structure which shows a somewhat starshaped structure with some of the networks nodes even drifted away from the other parts of the network the general explosion network for typhoon pigeon is relatively evenly structured with good connectivity all nodes have the same information transmission capacity results impact of the overall network on information dissemination impact of characteristics of the small world on information dissemination the two basic concepts depicting characteristics of the small world are clustering coefficient and characteristic path length to conclude all small worlds must have large average clustering coefficient and very small average path distance 2324 parameter 1 clustering coefficient the clustering coefficient is the average value of network density which can reflect to some extent the level of overlapping between individual networks in social network further the concept can be held as a characteristic index for network structure the clustering coefficients of tianjin explosion network and typhoon pigeon network were 0280 and 0599 meaning that the proportions of actual correlations of numbers of edges to the maximum possible correlations of numbers of edges between any adjacent nodes for the two networks were 280 and 599 respectively indicating a relatively smooth information communication locally having said that the clustering coefficient of tianjin explosion network was smaller than that of typhoon pigeon network which suggests that the relationship of the nodes of tianjin explosion network was kept relatively loosely the nodes of typhoon pigeon network were bonded closely at last the possibility of effective communication between different nodes in typhoon pigeon network was big parameter 2 average path length the average path length can directly reflect the transmission efficiency of social media network the shorter the average path length is the faster the information can transmit between different nodes in the network the nodes of tianjin explosion network and typhoon pigeon network were 396 and 51 respectively with corresponding average path length of 2882 and 1829 respectively it shows that the average path length of typhoon pigeon network was shorter than that of tianjin explosion network indicating a faster transmission speed for typhoon pigeon and a slower transmission speed for tianjin explosion the speed of information transmission has been slowed by the long information transmission chain which points to greater possibility on rumor generation both networks hadshorter average path lengths and higher clustering coefficients displaying evident characteristics of small world network which can help speed up information dissemination impact of basic network characteristics on information dissemination from the point of view of social network analysis the indicators of network degree distribution network diameter network density network correlation degree 25 26 27 28 are normally selected for the analysis on network feature parameter 1 average outdegree the average outdegree can reflect the breadth of information sources that is the larger the average outdegree the more likely the information can be obtained by the public also the psychological activities of the public on disaster information can also be inferred while the average outdegree of tianjin explosion network was 2396 the average outdegree of typhoon pigeon network was 325 indicating a more possibility for information transmission on typhoon pigeon it can be said then that although the number of nodes in tianjin explosion network is significantly more than that of typhoon pigeon network its average outdegree is less than that of typhoon pigeon network which on some levels can reflect the publics distrust on information on manmade disaster and their intention to pass down information flown solely from trusted sources or from those opinion leaders who hold discourse power in corresponding fields parameter 2 network diameter the network diameter refers to the maximum value of the shortest path between any two nodes in the network which is generally used to measure the network connectivity it can be used to calculate the coverage of the information and its distortion level for this paper in particular the network diameter of tianjin explosion network and typhoon pigeon network were calculated as 9 and 5 respectively indicating a long information transmission chain the long chain has led to a slow information transmission speed as well as a possibility of rumor dissemination 29 the social media was found to have a slow propagation rate and a high distortion rate on information which could have been caused by the division of factions inside the tianjin explosion network that is because of the sensitivity and conflicts of interests involved subjects of weibo were more willing to forward information passed down by their own people it has caused difficulty for the communication between different factions making communication paths between individuals of different factions longer which would be easily deduced through further analysis on the forwarding relationship of sina family parameter 3 network density network density is the ratio between the actual number of edges and the theoretical maximum number of edges in particular the network density describes the average level of relations of nodes of the social networks that is the closer the nodes are connected the greater the network density is in the case of tianjin explosion network the density of the network was calculated as 00303 indicating a low level of association and sufficiency of information among nodes in the case of typhoon pigeon network the network density was calculated as 03183 indicating a high level of relation and information exchanges among nodes in short the tianjin explosive network can be held as a low density network and which was symbolized with bigger clustering coefficient moreover it is difficult to conduct longdistance information communication within this type of social media network besides the communication in small groups can be said as relatively active parameter 4 network relevancy network relevancy refers to the proportion of relevancy between any two nodes in a directional network the higher the network relevancy is the greater the possibility for information to travel between these nodes in the network is in view of this paper the network relevancy of tianjin explosion network and typhoon pigeon network were calculated as 01633 and 03528 respectively the relatively low network relevancy of tianjin explosion network indicates there were many lonely information islands in the information dissemination and more oneway communication the collection of communication feedbacks has become harder as information cannot be received by groups on time the relatively high network relevancy of typhoon pigeon reflects that there were just a few lonely information islands in its information dissemination process the proportion of twoway communication on the network was relatively high the equal status of individual subjects ensured the coverage rate of information and efficiency of feedback collection the influence of subgroup characteristics on information dissemination as some nodes in the network were more closely related they form subgroup with certain characteristics which could be called as cohesive subgroup an analysis on network of subgroups can show clearly the internal structures of the networks the common characteristics of the nodes under the same subgroup and characteristic of relationships among different subgroups 30 analysis on the characteristic of the subgroup of tianjin explosion network using louvain algorithm tianjin explosion network have been divided into 26 subgroups in order to form intuitive understandings of the subgroups initially the nodes belonging to the same subgroup were classified by the method of shrinkage subnets 10 the specific operation steps can be described as below for the first step all nodes belonging to the same subgroup were shrunk to one particular subgroup node what is more in order to ensure that connections between different subgroups are not too loose it can be stipulated that a connection can be established only when the original connections between the subgroups are greater than 20 at last a subgroup network has been obtained as shown in figure 4 each node in the graph represents a subgroup and the number of original nodes in the subgroup varied from 1 to 155 among them subgroup a contained 155 nodes subgroup b contained 64 nodes subgroup c contained 49 nodes subgroup d contained 45 nodes subgroup e contained 36 nodes and subgroup f contained 26 nodes moreover all other subgroups not have shown here contained only one node the characteristics of internal nodes of subgroups a b c d and e were discussed below to form better understandings on compositions of different subgroups as well as the formation causes of relationships among subgroups furthermore the internal structures of subgroups a b c d e and f were displayed and analyzed respectively through the subnet extraction function of pajek software finally the structures of these subgroups were shown correspondingly as picture a b c d e and f in figure 5 on the characteristics of subgroup a this is an important subgroup which was related to subgroup b c d and e within the groups subgroup a transmitted information to subgroup b d and e as well as obtained information from subgroup b c and d however the objects from which subgroup a receives its information or pass its information were not exactly the same which indicates that the directions were not twoway for some information transmitted among different subgroups on the internal structure of subgroup a the subgroup was mainly comprised with weibo blogs published by celebrities and other unofficial organizations in addition it was found that 686 relationships were formed among 155 nodes of subgroup a the average outdegree was calculated as 874 and the network density was calculated as 00278 also the nodes within this group were loosely connected there was quite obvious difference among the core and peripheral nodes that is while some nodes were more closely connected to other nodes there were other nodes that have fewer connected nodes on the characteristics of subgroup b although the number of internal nodes of subgroup b was a lot less than that of subgroup a similar to subgroup a c d e and f subgroup b was formed by twoway connections they all acted as bridges between subgroup f and the other four subgroups obviously subgroup b was at the center of the network and so is very important for information transmission the internal structure of subgroup b shows the subjects of weibo accounts in subgroup b mainly included governmental departments dealing the explosion accident in tianjin and the news media which releases timely information to the public there were 1280 connections found among the 64 nodes of subgroup b with an average outdegree of 3606 and a network density of 02575 the node was closely related to one another indicating that a large number of weibo blogs has been forwarded with high level of risk communication compared with subgroup a there was no significant difference between the core and peripheral nodes of subgroup b third on the characteristics of subgroup c and d similar to subgroup a the subjects sending or obtaining the information were inconsistent the internal structure of subgroup c can be concluded as the subjects of two weibo accounts at the core position of subgroup c were cctv news and peoples daily the two statelevel news media while the weibo accounts on the periphery were owned basically by noncelebrities or the general public or individuals among them 60 relationships were established among 49 nodes of subgroup c with the average outdegree of 333 and the network density of 00476 the relationships between the nodes were quite loose not only that the subgroup c was formed by a very obvious coreperiphery structure a starshaped network which served as a bonus to the control of information accuracy the internal structure of subgroup d can be described as the core layer of subgroup d can be characterized as sina family which included such members as sina tianjin sina shandong sina henan etc this sina family presented as an important information source for tianjin explosion also the relationship of information transmission among subjects of the system was relatively equal and smooth the peripheral layer was formed by the noncelebrities or individuals of weibo accounts 231 relations were found between the 45 nodes of subgroup d with an average outdegree of 1283 and a network density of 01833 the relationship among the nodes was relatively close moreover there are evident hierarchical characteristics inside subgroup d it can be concluded then the core layers were formed by inner layers there were not too much position differentiation for the nodes in the core layers the outer layers were the peripheral layers on the characteristics of subgroup e the characteristic of subgroup e was found to be quite different from other subgroups while it obtained information from subgroup a and b it did not transmit information to other subgroups this indicates that while individuals inside subgroup e were willing to forward weibo blogs to other subgroups the individuals of other subgroups did not attach great importance to the information forwarded by individuals of subgroup e the internal structure of subgroup e can be concluded as the subjects of weibo accounts of subgroup e were often called as the little celebrities who were famous within their own respective communities or particular fields a total of 190 relationships were established between the 36 nodes of subgroup e which had an average outdegree of 760 and a network density of 00776 the nodes were relatively loosely connected relatively speaking the boundary between the core layers and the peripheral layers of the subgroup can be quite fuzzy with little geographical differences among subjects of the weibo accounts fifth the characteristics of isolated subgroups are many isolated subgroups in the network were owned by noncelebrities ie individual users of weibo accounts it can be seen from this graph that the number of likes obtained by these nodes was far more than the number of blogs that were forwarded this reflects that although weibo readers echo with information transmitted by noncelebrities considering the limited influence of the authors of the blogs in reality the motivation to transmit the information of the blogs is just not there the main characteristics of internal structure of isolated subgroups can be generalized as most isolated subgroups were owned by noncelebrities that is individual subjects of weibo accounts the characteristic of the isolated subgroup f can be generalized as follows 91 relationships were found among the 26 nodes the average outdegree of this subgroup was 700 with network density of 01346 the relationships between the nodes of this subgroup was relatively close there was no significant geographic difference between the core layers and the peripheral layers of subgroup f the subgroup of tianjin explosive network were classified mainly based on the nature of the subjects of the accounts which is to say that the identities of the subjects and the subjects common interest were key factors that can decide which groups the subjects of weibo accounts belong to risk communication was smother within the same group the structure of subgroup of tianjin explosive network was quite distinctive meaning the characteristics of risk communication and its transmission forms for manmade disaster were diverse and complex while the official subjects appeared more at the core of the network the public was seen more obviously on the periphery of the network analysis on the characteristics for the cohesive subgroup network of typhoon pigeon the structure of subgroup typhoon pigeon network was analyzed and then divided into five subgroups to analyze the characteristics of the cohesive network structure of typhoon pigeon and its possible influence on the risk information transmission similar to the analysis process on tianjin explosion the diagram of the subgroup structure of typhoon pigeon was obtained by extracting the network of the subgroups as shown in figure 6 it can be generalized based on the network structures of typhoon pigeons subgroup the type of structure of each subgroup network was relatively simple with no obvious coreperiphery structure the structure was similar to the globally coupled network that is any two subjects in the network are directly connected with each other with each subject having equal status in the network these characteristic of this type of networks ensured a relatively fast and accurate information transmission and just a few information islands because the subjects can get information directly from one another the network would be filled with confusing information and opposing views on the other the nature of the key nodes of the network display that the subject of the key nodes of typhoon pigeon subgroup networks was either media or the government who with their strong information identification ability can ensure the consistency of information and so can dissolve the issue of conflicting opinions to some extent it can be said from a functional point of view that typhoon pigeon network is a relatively pure information dissemination network the tianjin explosion network is not only an important network for information dissemination but also an important network for emotional communication impact of centrality on information dissemination the degree distribution analysis the degree distribution refers to the degree distribution of the nodes in the network a large number of research results show that the degree distribution of the actual network generally follows power law distribution combined with the characteristics of social media network the nodes outdegree has been selected for analysis the outdegree of a node refers to the number of times the information of the node is forwarded by other nodes the larger the outdegree is the more the information of this node is forwarded by other nodes and the more influential the information disseminated by this node might be the degree distribution of tianjin explosion network and the degree distribution of typhoon pigeon were drawn and shown in figure 7 on the one hand most blogs on sina hot topic of tianjin explosion has been forwarded less than 20 times with only a small number of blogs forwarded for more than 100 times showing that the flow of information has followed the distinctive pattern of powerlaws therefore tianjin explosion network had the robustness against random failure and vulnerability against deliberate attacks 3132 that is to say even if a piece of false information appears randomly in the network it is unlikely that it will affect the information accuracy of the whole network but if the key nodes of the network deliberately or not deliberately publish false information the information sent to the whole network will become untrustworthy therefore the attention must be paid to the role of the key nodes in weibo forwarding network so as to ensure the accuracy of key node information on the other hand the power laws distribution was shown weakly on the outdegree distribution of typhoon pigeon network with relatively equal frequency among intervals which proofs further on the lack of key nodes for the typhoon pigeon network the information stability of the network was strong which means that the probability of information distortion through one particular node was relatively small having said that if you want to send out fast messages to the whole network through a particular node or clarify rumors through the node the effect will not turn out to be good due to the lack of key nodes centrality and the structural holes centrality is a key index figure which can reflect the importance of a network node which can be further characterized as betweenness centrality closeness centrality and weight centrality 3334 the greater the value of betweenness centrality the higher the possibility of the node acting as an intermediary as well as taking a greater control on the network resources the greater the value of closeness centrality the closer the node is to the center of the network the weight centrality is used to weigh importance of one node from the perspective of the connection of this node to a key node in addition the constraint index of structural holes was introduced to examine the ability of a node in information and resources coordination the smaller the value of the constraint is the more important the node is the centrality and values of the constraint of tianjin explosion network and typhoon pigeon network were listed in table 1 it can be generalized that the centrality of the typhoon pigeon network was generally greater than that of the tianjin explosion which indicates that the nodes of the typhoon pigeon network were more tightly connected and more nodes were acting as the intermediaries and bridges during the process of information transmission however the constraints of the structural holes of typhoon pigeon network were found to be smaller than that of tianjin explosion network which suggests that the status of the nodes of typhoon pigeon network was relatively equal the nodes had relatively weaker control on information transmission it appears at first that the structural differences of the social media on the two events have caused different characteristics of the networks while the tianjin explosion network was close to a scalefree network which contained certain key nodes typhoon pigeon network was more like a regular type of network the constraints for the nodes of tianjin explosion network were valued higher meanwhile because of the small number of nodes in typhoon pigeon network the possibility of each node acting as the intermediary or the bridge has been increased which has produced generally bigger centrality figures through further analysis it was found that during the accident of tianjin explosions even when the public was enthusiastic about participating in the dissemination of relevant information and would love to carry out heated discussions due to the social sensitivity of the causes of manmade disasters the asymmetry of information and the authorities of information disseminators the public was seen only on the periphery of information dissemination resulting in a high constraint value for the overall network discussion it can be seen from the analysis towards two kinds of impacts of social media on different disasters for the social media network of manmade disaster it shows coreperiphery structure as well as the greater control capability of key node considering the technical complexity the social media network of this kind is endowed with both the function of information dissemination and emotional communication as a result this type of social media network presents the characteristics of factional divisions just like the actual social communities then the opinion leaders of the networks and other key nodes within the networks would exert greater influence on the communication networks furthermore while it is harder to conduct longdistance information communication the communication behavior inside the small groups can be relatively active at the same time for risk communication on this type of disasters relies heavily on key nodes namely the opinion leaders it would result in long information dissemination chains which is prone to rumor generation finally the speed of information transmission as subjected to the abilities of the key nodes is pretty slow whats more such social media networks are often vulnerable to deliberate attacks for example if some opinion leaders make mistakes or deliberately spread rumors it will more likely to cause panics to the network as a whole in view of the social media network of natural disaster it can be concluded that the social media network does not have a clear peripherycore structure and is a relatively pure information transmission network the network presents regular characteristics and a stronger connectivity for there are not many isolated information islands in the process of information dissemination the proportion of twoway communication has become higher which can ensure coverage and normal feedbacks of information however due to the lack of key nodes the nodes are found to have relatively weak controls over information dissemination that is if someone wants to quickly disseminate certain information to the whole network or to disseminate information through one particular note the effect will not turn out to be so satisfactory conclusions to let the social media have better effect on risk communication as well as to avoid risk the tianjin explosion and typhoon pigeon have been used as study objects in particular the discussion on the functional differences of social media on risk communication of manmade disasters and natural disasters has been carried out it is shown at last that social media exerts different effect on each type of risk communications while social media is mainly endowed with the function of information dissemination for risk communication of natural disasters it plays both communication role and the role of emotional exchanges for risk communication network of manmade disasters this can be concluded then that differences of network structure can result in different functions of social media in terms of manmade disasters the cluster effect of social media is more obvious moreover the opinion is unified for individuals of the same subgroup the information transmission is smooth less information is transmitted between different subgroups the antagonistic emotion exists inside each subgroup which has caused the role of opinion leaders extremely important at this point in contrast for the natural disaster risk communication differences are small for social media network structure the network connectivity is stronger information dissemination has become more efficient therefore only the accuracy of the information would be considered for risk communication on natural disasters what is more the use of such networks should change from the primary type of information dissemination to the more advanced type of knowledge dissemination disseminating not only basic information about the disasters but also deeper knowledge on how people should act in the face of such disasters in respect of risk communication of manmade disasters the aspects of information dissemination and emotional stability should be taken into considerationmoreover more focus should be paid on the construction of social relations rather than just information dissemination the results can help improve the theory of risk communication based on social relations optimizing the structure of disaster information transmission and changing the effect of risk communication

social media has brought opportunities and challenges to risk communication of disasters by undermining the monopoly of traditional news media this paper took blogs about tianjin explosion and typhoon pigeon posted through sina weibo as empirical objects moreover the paper used the analytical method of social network to conduct a comparative study on the network structures of information disseminated among different types of disasters with the goal of uncovering the impact of social media on different types of risk communication of disasters the result shows a different impact of the risk communication on the two types of disasters while the role of social media for the risk communication of natural disasters is mainly to influence information dissemination the roles of social media for the risk communication of manmade disasters are to transmit information as well as to communicate emotions the differences seen within the structure of social media networks are causes differences in functions specifically the structure for the social media communication network on manmade disasters takes on a core periphery structure which is endowed with both information communication and emotional communication functions also the role of the opinion leaders for the subnet is found to be significant while the communication within small groups is kept pretty active additionally the slow speed of information transmission of the network could result in easily distorted information on top of that the network is characterized with intense vulnerability to the attacks on core nodes in contrast the social media network for natural disaster risk communication is not seen with an obvious peripheralcore structure which is a relatively pure information transmission network with relatively equal principal status in other words the entire network is found with stronger connectivity and relatively faster information transmission speed furthermore the nodes inside the network are found to have weaker control over information transmission in sum the research results are helpful in improving the risk communication theory based on social relations optimizing the communication structure of disaster information so as to change the effect of risk communication

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introduction type 2 diabetes mellitus is a global epidemic which disproportionately impacts racialethnic minority populations and socioeconomically disadvantaged communities for example latin americans in the united states 1 are approximately 17 times more likely to have t2dm as compared to nonlatino whites moreover latinos are more likely to develop complications from diabetes than nlws as evidenced by a 15 times greater risk for visual impairment 20 times greater risk for end stage renal disease and 13 times greater likelihood of death 2 the treatment of t2dm involves engaging in a variety of diabetes selfcare behaviors across multiple domains including glucose monitoring dietary intake physical activity medication adherence and regular eye and foot exams 3 research reveals that t2dm treatment adherence is worse among latinos as compared to nlw particularly in the domains of medication blood glucose monitoring and selffoot exams poor selfcare leads to higher levels of hba1c as well as a greater risk for developing serious complications 5 6 7 8 hence there is a critical need to better understand the cultural and psychological factors relevant to diabetes selfcare behaviors among latino patients in the united states in order to reduce the deleterious outcomes related to this chronic disease research reveals that the complex and demanding treatment regimens associated with t2dm are often appraised negatively by patients resulting in increased distress 910 distress that manifests from the burden of living with diabetes 11 or diabetes distress broadly refers to patient concerns about diabetes management support the emotional burden of the disease and access to care 12 findings from an international study of diabetes patients from 17 countries including the us and mexico revealed that up to 45 of patients with t2dm experience diabetesrelated distress 13 this experience of diabetes distress is also more prevalent among racialethnic minority patients as compared to nonlatino white patients in the us 14 15 16 moreover one study revealed higher rates of diabetes distress among latino as compared to african american patients 17 further several studies have demonstrated the negative impact of diabetes distress on selfcare behaviors and glycemic control among diverse patient populations in the us including african americans and nonlatino whites 18 as well as among latinos in the us 19 and in south america 20 mitigating the complications of t2dm and related disparities among latino patients in the us requires the development of culturally responsive interventions that can effectively improve the management of this chronic disease while culture is increasingly recognized as an important factor relevant to the management of chronic diseases considerably less is known concerning how and to what extent these cultural beliefs values norms and practices impact psychological factors such as diabetes distress selfcare and subsequent disease outcomes one notable factor that has been found to be socially shared among diabetes patients in latin america pertains to beliefs about social exclusion 20 using a mixedmethods cultural research approach 23 qualitative interviews were conducted with diabetes patients in latin america resulting in the identification of socially shared beliefs concerning exclusion rejection and discrimination due to diabetes these socially shared beliefs about social exclusion were found to predict higher treatment distress and worse glycemic control among patients with t2dm 20 while research examining cultural beliefs about diabetesrelated social exclusion 20 shares some similarities with constructs such as stigma discrimination and social rejection these constructs are conceptually distinct namely the latter constructs have traditionally been investigated from the perspective of an individuals perception or experience of stigma discrimination social exclusion and social rejection while the former reflects cultural or socially shared beliefs that diabetes patients are rejected discriminated and excluded the bottomup cultural research approach 23 is a methodology that has reliably identified socially shared beliefs in a particular population or cultural group as previously discussed prior research employing this cultural research approach identified beliefs about diabetesrelated social exclusion that were socially shared among t2dm patients of latin american backgrounds 20 according to this operationalization of culture when a latino patient endorses an item such as a patient with diabetes feels excluded because of their disease it does not necessarly mean that this particular patient personally experienced exclusion rather it indicates that this individual much like other latino t2dm patients endorses a commonly held cultural belief that t2dm patients are excluded due to their disease according to the integrative model of culture and behavior guiding this research beliefs that are cultural or socially shared among members of a particular community have the potential to impact psychological processes and related behaviors and outcomes the broader literature on perceived or experienced social exclusion discrimination and stigma may provide preliminary evidence for the need to further explore the cultural construct among t2dm patients in the us social exclusion has been broadly defined as the experience of being kept apart from others emotionally or physically through rejection or ostracism 26 the core experience of rejection which involves being told or implied that one is not wanted can also include experiences of discrimination and stigmatization one can feel excluded in interpersonal relationships as well as at the societal level through messaging that ones social group is devalued 27 hence there is some conceptual overlap between the experience of social exclusion at an interpersonal level due to ones diabetes diagnosis and the experience of diabetesrelated stigma and discrimination at the societal level one of the contributions of this paper is that individuals who believe that diabetes patients are excluded or discriminated can be negatively impacted by this cultural belief even though they may not have personally experienced exclusion or discrimination due to their diabetes research investigating the perception or experience of discrimination among t2dm patients reveals significant associations with diabetes distress poor diabetes care hba1c and disease complications 28 29 30 31 less research has been conducted in the us on diabetes stigma however one exploratory study revealed that over half of participants perceived stigma in their family 32 another study including predominantly nonlatino white t2dm patients revealed that 52 perceived diabetes stigma which was associated with greater hba1c 33 it should be noted that much of the research on perceived or experienced discrimination and stigma conducted in the us included samples of participants from various racialethnic groups or predominantly nonlatino white patients from a cultural perspective a more nuanced understanding of the impact of these constructs appears necessary particularly among specific racialethnic populations such an approach is especially needed to better understand the experience of t2dm among latinos in the us who experience high rates of this disease compared to nonlatino whites and are historically underrepresented in medical research given the higher rates of diabetes distress and poor selfcare among latino patients as compared to nlws and in some cases african americans 4141517 there is a critical need for research to systematically examine how cultural beliefs associated with t2dm relate to psychological distress and in turn impact diabetes selfcare and outcome while multiple determinants of diabetes selfcare have been identified in the literature less is known regarding the multivariate nature of relations among these variables experts argue that in order to better understand the role of social and psychological determinants of health behaviors integrative theoretical frameworks are needed 34 as such the use of integrative models and multivariate statistical approaches could significantly advance knowledge in this area and lead to the development of more effective culturally responsive interventions 2434 betancourts integrative model of culture psychological processes and health behavior 232435 is one such model that specifies the structure of relations between social structural cultural and psychological factors as determinants of health behaviors such as those involved in the management of t2dm according to the integrative model aspects of culture such as the socially shared beliefs values norms and practices relevant to t2dm can directly impact health behavior including selfcare behaviors involved in the management of t2dm these aspects of culture can also indirectly influence health behavior through psychological processes such as the experience of distress associated with diabetes and medical treatment aspects of culture may be socially shared among members of groups such as those based on race ethnicity ses gender country of birth and other identities or communities health behaviors can also translate into biological outcomes such as hba1c in the context of t2dm this integrative model has been used to examine the role of culture in cancer screening disparities 243637 patientprofessional relations 25 seeking healthcare services 38 healthcare mistreatment 39 and diabetes outcomes 20 collectively these studies confirm the proposed structure of relations postulated by the integrative model namely several of these studies revealed that the impact of culture on the corresponding health behaviors and outcomes was indirect through various mediating psychological processes 20253639 and in some cases there was both a direct as well as an indirect effect of culture on health behavior and outcome 2038 the present study guided by betancourts integrative model of culture the aim of the present study was to systematically examine the complex nature of relations among cultural beliefs about diabetesrelated social exclusion and diabetes distress as determinants of selfcare and hba1c among latino patients with t2dm in southern california the research was conducted in san bernardino county california a community where latinos comprise the majority population san bernardino county also has some of the highest rates of t2dm in the state and the 3 rd highest diabetes death rates out of 58 california counties 41 consistent with the integrative model it was hypothesized that cultural beliefs about diabetesrelated social exclusion would directly andor indirectly impact diabetes selfcare through diabetes distress and that diabetes selfcare would in turn predict hba1c specifically it was hypothesized that 1 higher scores on cultural beliefs about diabetesrelated social exclusion would predict higher scores on diabetes distress 2 higher scores on diabetes distress would predict poor diabetes selfcare and 3 poor diabetes selfcare would be associated with higher hba1c method participants a total of 109 latino patients with t2dm were recruited from a diabetes treatment center in san bernardino county in southern california criteria for inclusion were having a diagnosis of t2dm being at least 18 years of age selfidentifying as latino american and able to read english or spanish one case was found to be an outlier resulting in a final sample of 108 the mean age of participants was 5574 639 identified as women and the average years of education attained was 1225 additional demographic information is provided in table 1 procedures approval for the study was obtained from the institutional review board at the authors university prior to data collection participants were recruited from diabetes education classes at a diabetes treatment center with permission from site administrators data collection occurred during the second of four diabetes education classes at the start of the scheduled class time bilingual spanishenglish research assistants provided a summary of the study and described eligibility criteria risks and benefits of participation and the estimated time to complete the instrument interested participants provided informed consent and were administered a paperandpencil instrument in either english or spanish participants were provided the opportunity to be entered into a drawing for a 50 amazon gift card as an incentive for participating in the study measures social structural sources of cultural variation participants responded to items assessing age gender yearly household income education country of birth and length of time since diagnosis according to the integrative model 23 these socialstructural variables are considered potential sources of variation in cultural beliefs participants indicated their yearly household income in us dollars based on five income categories ranging from less than 15000 to more than 100000 education level was reported in total years obtained from one year to 20 years or greater participants also indicated their ethnic background and noted their specific ethnic heritage country of birth was reported as a freeresponse item and then transformed into a dichotomous variable for the current study participants indicated the length of time since their diagnosis in years and months cultural beliefs about diabetesrelated social exclusion the cultural beliefs about diabetesrelated social exclusion scale was developed utilizing the bottomup cultural research approach to instrument development 23 with t2dm patients in latin america this cultural research approach begins with specific observations relevant to an area of research which are derived through interviews with the population of interest to this end qualitative interviews with 50 t2dm patients were conducted to identify socially shared beliefs values norms and practices relevant to t2dm and treatment adherence observations that were socially shared among the diabetes patients were identified as cultural in nature and quantitative items were then developed to assess these cultural beliefs values norms and practices an advantage of this approach is that it allows for the identification of aspects of culture directly from the population of interest rather than based on stereotypical views the scale that resulted from this bottomup cultural research approach was then psychometrically validated with a sample of culturally diverse patients with t2dm in southern california 4243 this threeitem cultural beliefs scale assesses socially shared beliefs relevant to exclusion rejection and discrimination due to diabetes participants were asked to think about patients who have diabetes and indicate the extent to which they agreed with the following statements a person with diabetes feels excluded because of their disease a person with diabetes feels rejected for doing the things recommended to control the disease and a person with diabetes feels discriminated against because of their disease item responses were based on a likert scale ranging from 1 to 7 while participants provided individual scores for each of these items the items were previously identified as cultural or socially shared through the bottomup cultural research approach hence higher scores indicated greater endorsement of this cultural belief by the participant responding to the cultural scale this scale demonstrated good reliability in the present study diabetes distress the diabetes distress scale2 an abbreviated version of the dds17 44 includes two items that measure the level of distress patients experience in the management of their diabetes the dds2 is a brief and psychometrically robust screening instrument with strong reliability as demonstrated in previous research 12 this scale has been utilized in prior research to examine diabetes distress in relation to various social structural factors psychological factors diabetesrelated health behaviors and t2dm outcomes participants rated the degree to which they felt like they were overwhelmed by the demands of managing diabetes and often failing with their diabetes regimen item responses were based on a likert scale ranging from 1 to 6 with higher scores reflecting greater diabetes distress the dds2 demonstrated good reliability in the present study poor diabetes selfcare the diabetes selfmanagement questionnaire includes items that measure selfcare behaviors relevant to t2dm management previous research has demonstrated that the dsmq is associated with clinical diabetes outcomes including hba1c 46 47 48 the scaling of items was adapted and utilized in the present study to assess selfcare behaviors over the past seven days the global selfcare item from the dsmq was selected for the present research because this single item has consistently performed well across various studies 4950 including our own pilot study conducted with a culturally diverse sample of t2dm patients 43 further a psychometric analysis of this global selfcare item revealed that it has high itemtotalcorrelations and compared to other items in the dsmq was the most predictive of hba1c 46 hence the item how many of the past seven days has your diabetes selfcare been poor was employed to provide an overall assessment of patients diabetes selfcare over the past seven days response options ranged from 0 to 7 days higher scores reflect poorer diabetes selfcare hba1c hba1c or glycated hemoglobin is a serologic marker that is principally used to measure diabetes treatment adherence over the past 90 days 51 higher levels of hba1c reflect worse diabetes control a hba1c test was administered by the diabetes treatment center which the participants reported at the time of data collection statistical analysis structural equation modeling with maximum likelihood estimation was used to test the study hypotheses using eqs 64 52 sem is a particularly flexible statistical technique that can be used with many research designs including crosssectional data 53 furthermore the analysis of mediation or indirect effects are fundamental to many sem analyses 53 since sem requires that the pattern of intervariable relations be specified a priori 54 research utilizing sem should be guided by strong theoretical frameworks the present study is guided by an integrative model of culture and behavior that specifies the structure of relations among sociostructural cultural psychological and behavioral factors data were screened for statistical assumptions which revealed a violation of normality no cases with substantial missing data greater than 30 were detected one outlier was identified and removed from the dataset prior to analysis resulting in a final sample of 108 participants data were assessed for missing completely at random via littles χ 2 test of mcar and missing variable analysis in spss 55 which suggested that the data appeared to be missing at random full information maximum likelihood estimation techniques were used to handle additional cases of missing data 56 a twostep sem building procedure was implemented to first test the measurement model and then the full structural model 57 adequacy of model fit for the measurement and structural models were assessed using multiple statistical criteria suggested by kline 58 robust ml estimation was employed to offset any observed nonnormality of the data by providing adjusted standard errors and indices of model fit 52 in addition the yuanbentler scaled test statistic was employed which demonstrates robust ability to detect good model fit with small sample sizes 59 the following criteria were used to assess good model fit nonsignificant yuanbentler scaled χ 2 goodnessoffit statistic with a χ 2 df ratio of less than 20 a nonrobust comparative fit index of 95 or greater a nonrobust standardized root mean square residual of less than 08 and a robust root mean square error of approximation of less than 08 with 90 cis less than 10 at the upper bound 60 61 62 in conjunction with theoretical and conceptual reasoning the lagrange and wald posthoc test statistics were reviewed to determine whether structural paths in the model should be added or eliminated and if so they were implemented in a stepwise manner 62 to test the indirect effect of cultural beliefs on poor diabetes selfcare via diabetes distress biascorrected bootstrapped confidence intervals were calculated using the product of coefficients method 6364 statistical power current methods to calculate statistical power in sem are not wellestablished 65 multiple factors influence the power of sem including the associations between indicators and related constructs the number of latent variables sample size effect size desired type 1 error rate normality and degrees of freedom in general the greater degrees of freedom a model has the smaller sample size needed to attain the desired power level based on the number of latent factors and indicators for each factor as well as the number of other indicators in the proposed model it was estimated that a sample size of 110 participants would be necessary to achieve an 80 probability of detecting a truly significant effect 65 results preliminary analyses table 2 reflects the means standard deviations and correlations among the study variables a review of bivariate correlations revealed several significant associations between cultural beliefs about social exclusion diabetes distress poor diabetes selfcare and hba1c the measurement model which consisted of two latent factors with five indicators fit the data well yuanbentler scaled χ 2 3031 p 552 χ 2 df 758 robust cfi 1000 srmr 020 robust rmsea 000 90 ci 000 128 hence no adjustments were made to the measurement model prior to testing the study hypotheses tests of study hypotheses a structural equation model including the hypothesized theorybased relations among cultural beliefs about diabetesrelated social exclusion diabetes distress poor selfcare and hba1c was tested gender age household income education time since diagnosis and country of birth were also included in the tested model as sources of variation in the cultural factor a review of the fit indices and the lagrange multiplier test statistic suggested that adding a path from country of birth to hba1c and time since diagnosis to diabetes distress and poor diabetes selfcare would improve model fit a review of the wald test statistic suggested dropping the path from cultural beliefs about social exclusion to poor diabetes selfcare would improve model fit the resulting structural equation model including the hypothesized theorybased relations fit the data well yuanbentler scaled χ 2 59253 p 323 χ 2 df 1021 cfi 990 srmr 063 robust rmsea 027 90 ci 000 067 the study variables accounted for 18 of the variance in diabetes selfcare and 132 of the variance in hba1c consistent with the study hypotheses cultural beliefs about social exclusion predicted diabetes distress and diabetes distress predicted poor diabetes selfcare specifically higher scores on cultural beliefs about social exclusion predicted higher scores on diabetes distress which in turn predicted poorer diabetes selfcare there was a trend in that poor diabetes selfcare was associated with higher levels of hba1c although not central to the study hypotheses results revealed that country of birth was a significant predictor of hba1c such that patients born in the us reported higher levels of hba1c regarding the sources of cultural variation greater length of time since t2dm diagnosis was significantly associated with cultural beliefs about social exclusion as did younger age discussion the present study examined the role of cultural beliefs and diabetes distress as determinants of diabetes selfcare and hba1c among latino patients with t2dm in the us consistent with the structure of relations in betancourts integrative model of culture psychology and health behavior 232435 results revealed that when participants held cultural beliefs that diabetes patients are socially excluded rejected or discriminated due to their disease they were more likely to experience distress associated with managing their diabetes furthermore patients who had heightened levels of diabetes distress were more likely to engage in poor diabetes selfcare which was associated with worse glycemic control these findings provide a comprehensive understanding of the multiple determinants namely the socialstructural cultural and psychological factors predictive of diabetes selfcare and outcome among latino patients with t2dm findings from the present study extend prior research on diabetes distress that has largely investigated its impact on behaviors associated with diabetes selfcare and outcome 204566 other researchers have argued that while there is considerable research reporting higher rates of distress in ethnic minority patients with t2dm few studies have directly investigated why this may be the case 14 hence this study adds to the body of literature on diabetes distress by demonstrating that there are important cultural antecedents of diabetes distress that should also be taken into consideration such an approach provides greater clarity and understanding regarding the factors that contribute to increased diabetes distress while also providing valuable information that can be used in the development of interventions to address distress while culture has been noted as an important factor in the context of health the scarcity of psychometrically validated cultural instruments serves as a barrier to moving research forward in this area the present study utilized a cultural research approach to instrument development 23 to identify cultural beliefs relevant to behaviors associated with diabetes selfcare a cultural factor that emerged from prior research conducted in latin america had to do with patients beliefs that they are socially excluded due to their disease 20 based on results from the present study it appears that these same cultural beliefs about social exclusion are particularly relevant to latino patients in the us furthermore among us latinos an important finding was that these cultural beliefs about social exclusion led to heightened levels of diabetes distress these findings suggest a potential benefit for interventions that address beliefs about social exclusion among diabetes patients results also highlight the various social structural factors that serve as sources of cultural variation specifically patients who were younger endorsed higher levels of the socially shared beliefs about social exclusion it may be that younger as compared to older individuals are more impacted by cultural concerns around social exclusion additionally individuals who had t2dm for a longer period of time reported higher levels of these cultural beliefs as patients live longer with t2dm it is possible that they are interacting with other diabetes patients to a greater extent and may have more opportunities to either experience or observe others being socially rejected or discriminated due to their t2dm in fact recent research suggests that individuals who lived with diabetes for 1115 years had higher scores on a selfstigma scale compared to those that lived with t2dm less than five years 67 although having a family history of t2dm was not assessed in the present study it should be taken into consideration in future research for example would having family members with t2dm attenuate the likelihood that an individual endorses cultural beliefs about social exclusion or could it exacerbate the likelihood scollankoliopoulos and colleagues 68 found that patients who had family members experience social consequences due to having diabetes were more likely to have similar perceptions an interesting finding concerning the social structural factors included in this study was that latino participants born in the us had higher levels of hba1c as compared to foreignborn latinos this is consistent with previous research demonstrating that latinos born outside of the us have better health outcomes as compared to latinos born in the us 69 and that latino immigrants in the us experience better diabetes outcomes compared to us born latinos 70 as detailed in previous research on health outcomes among latino immigrants in the us the present study findings can be attributed to multiple factors one of which includes the role of acculturation for example abraidolanza and colleagues 73 found that more acculturated latinos in the us had a greater likelihood of high alcohol intake current smoking and high bmi which are all risk factors for t2dm complications on the other hand there are a number of protective factors associated with maintaining aspects of ones cultural beliefs values norms and practices 35 that could help to explain the beneficial effects of foreign born status on hba1c as noted in the present study the finding that socialstructural cultural psychological and selfcare variables accounted for a notable proportion of the variance in the biological outcome hba1c has conceptual as well as clinical implications while the integrative model of culture psychology and health behavior 232435 has been employed to better understand the influence of socialstructural cultural and psychological factors on health behaviors such as cancer screening healthy eating and physical activity 194043 it has only recently been used as a conceptual framework for explaining biological outcomes results from the present study provide additional evidence concerning the mechanisms by which culture may impact biology highlighting the critical role of psychological and behavioral phenomena namely structural equation modeling revealed that the influence of culture on diabetes selfcare was indirect through the influence of diabetes distress the present study draws attention to the importance of not only testing the effect of culture on behaviors and outcomes relevant to t2dm but also the need to test for mediating psychological factors relevant to the cultural and behavioral phenomena of interest from a clinical perspective the fact that the hypothesized model including social structural cultural psychological and behavioral factors relevant to t2dm accounted for 132 of the variance in the biological outcome hba1c a marker of disease progression is significant paddison and colleagues 75 conducted a study with t2dm patients in australia and found that psychological perceptions of diabetes accounted for approximately 8 of differences in metabolic control the authors argued that because these psychological factors made a unique and statistically significant impact on physiological outcomes modification of psychological views could help to produce more positive disease outcomes based on findings from the present study it could be argued that interventions which target both cultural and psychological factors could produce an even greater impact on t2dm outcomes still due to the use of crosssectional data in the present study there is a possibility that individuals with poor glycemic control in turn experience greater diabetes distress and cultural beliefs about social exclusion although the structural equation model tested in the present study was hypothesized a priori based on theory and results from sem did not support a path from hba1c to diabetes distress or cultural beliefs a more definitive test of these relations using longitudinal data is warranted the development of culturally relevant interventions designed to reduce diabetesrelated distress among latino patients with t2dm is clearly warranted while research points to the success of interventions aimed at reducing diabetes distress their impact on diabetes selfmanagement is only modest 76 at the same time a systematic review revealed that culturally tailored lifestyle interventions for diabetes prevention were modestly effective in reducing the risk of diabetes among latinos in the us 77 interestingly few of the interventions included in that systematic review specifically addressed cultural beliefs about diabetes one might argue that in the case of interventions with diabetes patients as compared to interventions aimed at preventing the onset of diabetes it would be even more critical to address patients cultural beliefs about t2dm collectively these intervention studies suggest that perhaps simultaneously addressing both cultural and psychological factors could produce more significant effects on diabetes selfcare and outcome such an approach could contribute to reducing the noted disparities associated with t2dm complications and mortality rates between latinos and nlw in the us considering that the cultural belief of social rejection and exclusion is shared among latino patients with t2dm and associated with heightened diabetes distress interventions could benefit from addressing this particular cultural barrier while also drawing from potentially protective cultural aspects for example interventions could take into consideration familism a cultural value considered central to some latinos which emphasizes warm close supportive family relationships and the prioritization of the family over the self 7879 research indicates that familism is associated with increased social support and better psychological health 80 and therefore may serve as a potential protective factor in reducing diabetes distress and risk for disease complications this cultural value could be particularly beneficial in reducing latino diabetes patients cultural beliefs about social exclusion and rejection due to their disease while at the same time reducing the likelihood of diabetes distress the current study also highlights opportunities for future research for example there is a clear need for research with other racialethnic minority populations and low ses populations that are disproportionally affected by t2dm and likely experience increased diabetes distress associated with poor selfcare and outcomes hence the cultural research approach and integrative model utilized in the present study could also be applied with other populations experiencing disparities in t2dm as well as within the context of other chronic diseases that pose significant public health concerns in line with this future research could especially benefit from employing an integrative approach to the study of culture on health behavior using robust statistical techniques to investigate contributing cultural psychological and behavioral factors on specific chronic diseases and identify andor clarify pathways to poor chronic disease outcomes among socially economically or educationally disadvantaged populations in light of the study findings there are some limitations of the research that should be considered first although this research includes a relatively large clinical population of latino patients with t2dm for the purposes of structural equation modeling this sample size may have resulted in greater difficulty to detect additional significant paths still findings from the use of the yuanbentler statistic for small sample sizes suggested excellent model fit 59 and our power analysis indicated that we were only two participants short of the suggested minimum sample size for detecting significant effects second the biological outcome hba1c was selfreported which is not as preferable as obtaining this data from a chart review still the diabetes treatment center conducted a test of participants hba1c one week prior to data collection suggesting that the selfreport may be less vulnerable to memory bias in a similar vein the global item used to assess diabetes selfcare may also be vulnerable to subjectivity and selfreport bias third results are based on findings from a sample recruited exclusively from southern california with participants predominantly identifying as mexican american as such it is unclear whether results from the current study would be the same with latino patients from other regions of the us that represent individuals from different latin american origins moreover participants were recruited at the second of four education classes at a diabetes treatment center hence the generalizability of the study findings to other populations of t2dm patients such as those who could not attend education classes were uninteresting in attending or who only attended one class should be viewed with caution fourth although all participants selfidentified as latin american due to formatting issues with our instrument over half did not further specify their specific ethnic background hence it was not possible to examine within group differences in the study variables finally while the tested propositions are solidly grounded in theory that operationalizes culture as a relatively stable construct the use of a crosssectional design limits the test of temporal relations therefore future research utilizing a longitudinal methodological approach could be particularly beneficial to rule out the possibility of bidirectional relations 81 despite these limitations this study has several notable strengths the present study demonstrated the advantages of examining the role of culture in health behavior using an integrated framework by simultaneously testing the effects of socialstructural cultural and psychological factors as determinants of diabetes selfcare and outcome furthermore latent variable statistical modeling techniques allowed for a comprehensive examination of these relationships simultaneously rather than focusing on a test of these individual variables this study also employed a previously validated cultural instrument developed using the mixedmethods cultural research approach to instrument development 23 as such it was possible to investigate a cultural variable considered central to latino patients experiences of t2dm thereby improving the translatability of the research findings necessary for the development of culturally relevant interventions finally the current study is particularly significant from a public health perspective given that the research was conducted in a region of southern california with high rates of t2dm as well as some of the worst diabetes mortality rates 41 research involving human participants andor animals this article contains a study with human participants this article does not contain any studies with animals performed by any of the authors competing interests the authors declare no competing interests open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

background type 2 diabetes mellitus t2dm disproportionally impacts latin americans latinos in the us compared to nonlatino whites as reflected by an increased risk for disease complications and higher mortality rates guided by an integrative model of culture psychological processes and health behavior the purpose of the present study was to examine the role of cultural beliefs and diabetes distress as determinants of selfcare behaviors and hba1c among latino patients with t2dm methods participants included 109 latino patients with t2dm recruited from a diabetes treatment center located in a region of southern california with high diabetes mortality rates structural equation modeling was employed to examine the extent to which cultural beliefs about diabetesrelated social exclusion and diabetes distress impact selfcare behaviors and selfreported hba1c results consistent with the study hypotheses cultural beliefs about diabetesrelated social exclusion predicted diabetes distress which in turn predicted poor diabetes selfcare conclusions findings suggest an important need for intervention efforts that address both cultural and psychological factors in order to improve diabetes selfcare behaviors and associated disease outcomes among latino patients with t2dm future research could benefit from investigating protective aspects of culture that could help counter the negative implications of cultural beliefs about social exclusion and diabetes distress associated with poor selfcare

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introduction the burgeoning number of internet users participating in healthcare virtual support communities has drawn researchers from various fields to study the online social support phenomenon in the literature on online support studies however little attention has been paid to the provision of social support as a dependent variable ie the discovery of the psychological relational or contextual determinants that predict the provision of social support 2 such identification is essential to the investigation support receivers as well as providers health outcomes 34 additionally for practitioners and virtual community administrators identified determinants can also lead to appropriate healthcare intervention and improved design of the online environment to facilitate support exchange 5 for healthcare organizations seeking to enhance the quality of their offerings through virtual community initiatives 6 knowing the determinants of individual online helping behaviors can also lead to more effective collaboration with them for organizations pursuing new knowledge management systems or other information systems the identified determinants can also shed lights on employees voluntary contribution of help 7 this study attempts to bridge the gap in the literature on healthcare virtual support communities by examining the determinants of the provision of informational and emotional support the most common types of social support exchanged online 9 more specifically different aspects of relationships formed among members of a virtual support community characterized by the structural relational and cognitive dimensions of social capital 10 are conceptualized as the predictors of the contributions to the two types of social support this study makes three main contributions first this study represents one of the few attempts to explore the determinants of support provision and is the first endeavor to systematically investigate this topic in online contexts second this study is the first to examine the applicability of nahapiet and ghoshals social capital framework 10 in which social relationships are characterized through the structural relational and cognitive dimensions of social capital to online social support activities the third contribution of this study is the use of an automated method to analyze online messages an automated analysis method would generate more reliable results by better representing the dynamics of the target community due to its ability to analyze data spanning a long period of time 11 this article is organized as follows section 2 provides the theoretical background the proposed research model are then presented in section 3 in section 4 the method for testing the proposed model is discussed which is followed by results discussion and conclusions in section 7 theoretical background social support and virtual support communities lakey and cohen 12 defined social support as aid and assistance exchanged through social relationships and interpersonal transactions the social support phenomenon has been studied for decades as researchers endeavored to theorize about social support functions and to investigate the role that social relationships and social support embedded therein play in mediating individuals life stressors social support has been found to have positive effects on individuals physical and mental health 13 in the age of the internet the number of virtual support communities has grown exponentially 14 such communities are based on the premise that people who share similar difficulties or disease would be better able to empathize with one another and exchange support 15 features of virtual support communities such as anonymity invisibility and delayed reactions allow community participants to disclose information about self safely without the fear of being stigmatized create a sense of solidarity and enhance the feeling of personal empowerment 15 in this study the phenomenon of social support is studied in the context where resources are actually provided to support receivers 13 instead of ones subjective perception of being cared and supported by others 2 among the social support studies based on this view the types of support that are exchanged and the function that each type of support has on individuals have been a common interest according to recent findings 917 informational support and emotional support have emerged as the most common types of support exchanged online social capital and its dimensions social capital 18 19 20 refers to the existence of social relationships and the relational assets such as identity trust and social norms that are embedded within the relationships the emergence and maintenance of social capital allows connected partners to share benefits such as increased accessibility to useful information 18 and increased community solidarity 19 by providing a theoretical foundation to explore and seek explanations for various social phenomena social capital theory seems appropriate to this study this study is based on nahapiet and ghoshals conceptualization of social capital wherein the properties of social relations within an organization are linked to the creation of organizational knowledge 10 in their conceptualization facilitated organizational knowledge exchange and combination are the benefits embedded within social relations which are characterized by three dimensions of social capital structural relational and cognitive 10 in this study the level of analysis is at the individual actor level 21 the dimensions of social capital are operationalized and measured for each member connecting to others in the community figure 1 illustrates the proposed model hypotheses structural dimension of social capital and support provision the structural dimension of social capital in this study is manifested as the extent to which one engages in social interaction with other members in message threads she participates in which captures the intensity of ones social relationships through regular social interactions with other group members one has better access to these members information and support and thus has higher awareness of their needs 2223 he or she is also more likely to be asked by these members for support 2223 this results in higher opportunities for himher to engage in supportive interactions barnes and duck also suggested that frequent social interactions set up a context that fosters support exchange 24 as virtual support community members interact through their participation in the same discussion threads channels of support between them will also be created hence h1 the extent to which an individual of a virtual support community interacts with other members is positively associated with hisher contribution of emotional support and informational support relational dimension of social capital and support provision in this study we consider social identification as a relational asset that is embedded in social relationships and motivates ones provision of informational and emotional support in virtual support communities social identity theory 25 concerns ones psychological state by which one sees oneself as a member of and belonging to a social group research has shown that ones sense of social identity fosters hisher prosocial citizenship behaviors toward the group she belongs to and its members 26 for example sharing of a common group identity has been found to contribute to the feelings of responsibility for the welfare of others and thus ones helping behavior 27 even when the person who receives help is a stranger to the provider 28 in online environments group identity has also been found to predict virtual community members knowledge sharing behavior 29 as a result when a member of a virtual support community identifies with the community she is more likely to provide support to those who are in need even if they do not know and never see each other hence h2 an individuals degree of social identification with a given virtual support community will positively influence hisher contribution of emotional support and informational support to other members cognitive dimension of social capital and support provision the cognitive dimension of social capital refers to the shared knowledge mental models and language that are embedded in social relationships 10 adler and kwon regarded the cognitive dimension of social capital as ones ability to exchange social capital benefits 21 this dimension of social capital is thus tightly related to ones expertise and the exchange of expert knowledge across social relationships 7 even if relationships among community members afford the opportunity and motivation to contribute useful information contribution is not possible unless one correctly interprets the others needs can evaluate the context in which others need the resource and knows what to provide 721 it has also been shown that one is less likely to contribute knowledge to other community members when one feels a lack of ability to do so 30 therefore in virtual support communities informational supportthe provision of knowledge about a problem and how to solve it is more likely to be provided by members with greater healthcarerelated expertise as a result we hypothesize h3 an individuals degree of healthcarerelated expertise is positively associated with his or her contribution of informational support in the target virtual support community method this study contains two stages of data analysis to study the proposed model we first adopted manual and automated content analysis methods to analyze online message content and classify them into different categories based on the results of the content analysis methods we used structural equation modeling method to test the hypotheses data collection the target virtual support community for this study is a large us based virtual cancer support community that hosts discussion boards for various kinds of cancers and has more than a hundred thousand registered members posting hundreds of messages to these boards every day breast cancer discussion board the most active cancer discussion board of this virtual community was chosen as the data source from which messages were collected discussion threads from the discussion board initiated within these four different time periods the first week of may 2011 the first week of october 2011 july 1 2012 through august 31 2012 and september 1 2012 through october 31 2012 were downloaded for investigating the research model the collected data spanning four time periods pertains to three separate data sets used for different purposes the information about the collected messages is listed in table 1 respondents participants of this study were derived from the 2 nd downloaded data set ie participants of discussion threads initiated during the twomonth period from july to august 2012 based on the user id which is unique for each registrant a total of 293 community members were identified from the collected messages in order to have a complete record of individual online social interactions that took place across the twomonth period from july 1st to august 31st we eliminated those who registered during this period this resulted in 187 community members our aim was to study the causal relationships between the social characteristics of these 187 members in terms of their structural relational and cognitive dimensions of social capital as measured during july and august 2012 and their subsequent provision of informational support and emotional support during september and october 2012 data analysis based on the three data sets two stages of analysis were conducted the first stage consisted of conte analyses of collected messages first manually and then automatically to classify them into predefined categories the goal of manual classification is to generate the training data for the computer program to learn to classify support messages into either informational support or emotional support automatically 11 two coders1 analyzed the first data set which consists of 100 message threads and classified it into message threads initiated either for social support exchange or for companionship activities based on the definitions and purposes of these two types of activities 2we chose to first classify message threads into these two types of social activities since they are the two primary activities that members of virtual support communities engage in 32 and our focus is specifically on social support activity cohens kappa 33 was used to measure intercoder reliability resulting in the value of 86 disagreements were resolved through discussion this manual classification task resulted in 40 threads that were initiated for companionship purposes and 60 threads for social support exchange the second manual classification task focused on the 60 remaining threads that were about support here the individual message posting was chosen as the basic unit of analysis each of these 795 messages was further manually classified into message posted for either informational or emotional support if more than one support type was provided in a support message the primary focus or the predominant one was coded the resulting intercoder reliability was 90 after the manual classification results of informational support and emotional support messages were generated these classified messages were then used to train the computer program coded with machine learning algorithms to classify the two types of support messages automatically specifically we used the libsvm software library 34 to do the training and automated classification a 10fold crossvalidation method 35 3 was used to evaluate the goodness of the trained computer program yielding a 9248 average classification accuracy the process described above was repeated using the 2 nd and 3 rd data sets that is first the total of 877 threads from the two data sets were manually classified into threads for support exchange or for companionship activities messages from the support threads were then classified into messages for either informational support or emotional support due to the large amount of support messages involved manual classification would have been time consuming and errorprone instead the previously trained automated support classifier was applied to classify the total of 6848 messages into either messages for informational support or for emotional support at the second stage of the analysis independent and dependent variables used for testing the hypotheses were prepared and the proposed model was tested as noted earlier the variables in this study were generated from objective data such as online message content the use of objective data for analysis avoids some potential biases associated with other widely used research methods such as survey questionnaires 36 it also provides a different perspective on the phenomenon of online support exchange table 2 summarizes the variables used in this study as indicated above the unit of analysis for hypothesis testing was each individual community member independent variables structural dimension of social capital in order to measure the extent of social interaction construct three indicators were used postthread ratio exchanged postthread ratio and average exchanged posts with an alter per thread these indicators are expected to measure the average activity of a member within a given thread the average interactivity of each thread a member participates in and the average pairwise interactivity of each thread a member participates in respectively the postthread ratio is expected to measure on average the degree to which a community member engages in discussion threads she participates in the higher the value on average the more messages she posts when involved in a thread in addition to this indicator we also consider messages posted by others in threads a given member participated in the exchanged postthread ratio for a community member is intended to capture the average number of messages posted by all the posters of the threads a given member participated in put in other words it measures the average amount of information a given member is exposed to when she participate in a discussion thread the average exchanged posts with an alter per thread indicator is about information exchanged between pairs of community members we consider that information is exchanged between community members when they post messages in the same thread for a given member this indicator measures the average number of messages exchanged between himher and each of those who had ever participated in a thread together with himher more specifically this is done by measuring the average number of messages posted both by the given member and an alter for all the threads they both participate in together such a calculation was carried out for all those who had ever participated in thread together with the given member this indicator is intended to measure the average amount of information exchanged between a member and an alter when they coparticipate in a thread relational dimension of social capital the social identification construct of the relational dimension of social capital can be assessed by three indicators the ratio between individual use of wewords and iwords in hisher messages the number of reciprocal friends one possesses and ones tenure in the virtual support community to calculate community members use of wewords and iwords we used the linguistic inquiry and word count 37 to analyze collected messages the liwc is a research tool used to search text documents and count the frequencies of the occurrence of words belonging to each of the 68 predefined word categories in this study the first person plural pronouns and the first person singular pronouns categories were used to measure ones level of social identification as researchers have suggested that the use of wewords and its comparison to iwords usage in texts are a marker of shared social identity in online environments in the target cancer support community each member can explicitly designate other members to be hisher friends this friendship assignment is not necessarily reciprocal which means a member a can assign another member b as friend without bs assignment of a as friend as a result when two community members assign each other as friends it can be seen as that the two members recognize each other as friends forming close social bonds hogg and abrams 25 argued that a sense of group identification begets liking between members of the same group in other words the more reciprocal friends one has the more one identifies with the target virtual support community in addition we also consider an individuals tenure in the target virtual support community as an indicator of social identification as an individuals tenure in a virtual community increases due to hisher history of interaction with other members it is likely that hisher feeling of attachment and sense of belonging and the perceived similarities between the individual and other members also increases leading the individual to identify more with the community 3940 cognitive dimension of social capital to assess an individuals level of healthcarerelated expertise two indicators were used the average number of the unified medical language system terms used in each informational support message one posted and the number of nonreciprocal incoming friendship assignments one has umls 41 is an online metathesaurus of controlled vocabularies of biomedical terminologies which was developed by the us national library of medicine each term in the umls belongs to one or more of the total 135 semantic types such as disease or syndrome mental or behavioral dysfunction or therapeutic or preventive procedure we used metamap a software tool that applies the umls for identifying biomedical terms in texts to analyze collected messages and map word occurrences to umls semantic types 42 here we measured the average number of umls terms used in each informational support message one posted which represents ones ability to apply hisher knowledge in the provision of informational support social comparison theory 43 suggests that people under anxiety conditions are likely to affiliate and seek information from those who adjust better than themselves 44 this tendency of upward affiliations allows individuals to simultaneously acquire guidance from these experts for coping with the stressors and treat experts as role models to provide hope and inspiration for themselves 44 it can thus be inferred that members of virtual support communities who have a high degree of nonreciprocal incoming friendship assignments from other community members are expected to have either overcome their threatening circumstances or adjusted well 44 and thus have higher expertise dependent variables individual provision of informational support and emotional support are the two dependent variables in this study to assess the two constructs we measured the quantity and effort aspects of support provision as indicators in other words for each community member the number of informational and emotional support messages she posts and the average number of words in hisher provision of informational support and emotional support message ie the effort she took to provide support were calculated results to test the proposed hypotheses we chose partial least squares analysis a componentbased approach to sem for model validation and structural model testing the smartpls 20 software package 45 was used for data analysis in this study 4 measurement model validation we assessed the indicator reliability convergent validity internal consistency reliability and discriminant validity of the measurement model 4647 as can be seen in table 3 the factor loadings for the indicators are 06 or higher suggesting indicator reliability 5 in addition the values of the average variance extracted and composite reliability as shown in table 4 are greater than 05 and 07 respectively suggesting convergent validity and internal consistency reliability of the measurement model lastly table 4 shows that all the square roots of ave exceed the corresponding interconstruct correlations providing evidence of discriminant validity as for the proposed hypotheses an individual members extent of social interactions with other members in a thread is positively related to hisher contribution of emotional support as is hisher social identification with the community however an individuals extent of social interaction and hisher level of social identification failed to predict the provision of informational support rejecting hypotheses 1b and 2b as predicted an individuals level of healthcarerelated expertise significantly and positively predicted hisher informational support contribution structural model testing discussion this article attempts to answer the question of what leads to individual contributions of social support in healthcare virtual support communities the results suggest that although both the extent of social interaction and social identification are positively and significantly associated with ones provision of emotional support they fail to significantly predict the provision of informational support a possible reason that h1b and h2b were not supported may be due to the fact that even if one has the opportunity to share information and is motivated to share information one may still be reluctant to contribute if she lacks the ability to help 21 when a community member asks for information about a medication and its side effects symptoms of a disease a healthcare provider or an insurance plan other members may not be able to help if they do not have the knowledge to do so as hypothesized an individuals healthcare related expertise significantly predicted hisher provision of informational support the implication for website designers as well as healthcare organizations aiming to facilitate individual participation in virtual support communities is to identify experts in the community and work with them to encourage the provision of informational support by examining individual use of biomedical terms in supportive messages experts in the community can be discovered furthermore people can analyze community members uses of personal pronouns friendship status or their tenure in this community to locate those who are more identified with the community through the collaboration with those experts andor committed members to build a virtual community conducive to social interactions the community will have greater longevity healthcare intervention through virtual support communities will be more effective and healthcare organizations can also cocreate value with community participants from the facilitated exchange of support 6 we should note some limitations first an inevitable limitation of conducting automated content analysis is that it introduces certain classification errors to solve this problem future studies should employ parallel research methods such as survey questionnaires to triangulate the research findings this can also lead to a more meaningful analysis of the dynamics of the virtual support community because the target virtual support community of this study is usbased the generalizability of the findings to virtual support communities located in different countries could be limited however because anyone in the world can register and participate in the target virtual support community we believe this limitation is alleviated to some extent still replication and comparison of this study to see if virtual support communities of different countries exhibit similar dynamics is worth performing third this study intentionally classified online user activities into companionship activities informational support and emotional support such an exclusive and exhaustive classification may underestimate the messy real world situations in which a message may be posted by an individual to serve multiple purposes more insights into the complexities of online relationships and their impact on social support provision require future research to reflect the nature of social activities lastly in this study indicators for measuring the extent of social interaction construct were used for the first time in the literature as a result the validity of these indicators needs to be further examined future study should assess the suitability of these indicators in capturing this aspect of social capital conclusion this study aims to conceptualize the relationships between social capital and the provision of social support in virtual support communities the structural dimension of social capital manifested as the extent of social interaction was hypothesized to provide opportunities for community members to provide social support the relational dimension manifested as social identification was hypothesized to motivate individuals to provide help the cognitive dimension manifested as individual healthcarerelated expertise was hypothesized to capacitate individual to share knowledge with other members this study not only provides insights into the design and administration of virtual support communities but it could also be the basis of future endeavors for improving the social and health outcomes of participation in such communities generating independent variables as with 49 and 7 data collected for testing the proposed model was separated into two time periods to address the mutualdependence issue between the independent and dependent variables in more specific the messages used for generating independent variables were those that were posted two months prior to the messages used for generating dependent variables this helps ensure the causal direction to be tested in our model postthread ratio total of msgs posted by the member total of threads to which the member posted msgs exchanged postthread ratio total of msgs in threads to which the member posted msgs total of threads to which the member posted msgs average exchanged posts with an alter per thread ∑ of msgs posted by a given member and an alter in all threads that they participated in together of threads that they participated in together ୣୟୡ୦ ୟ୪୲ୣ୰ of distinct alters in all threads to which the member posted msgs social identification we to wei ratio of we words occur in the member′s msgs of we words i words occur in the member′s msgs

drawing from social capital theory this study attempts to present a model that applies the structural relational and cognitive dimensions of social capital to theorize the determinants of the provision of informational and emotional support in healthcare virtual support communities the results show that individual provision of emotional support is determined by hisher extent of social interaction with other community members and hisher social identification with the community moreover ones contribution of informational support can be predicted by hisher level of healthcarerelated expertise

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introduction marriage is regarded as a means to establish an unbreakable relationship between two families as an important social institution marriage is a basic need for the family the family is one of the universal and permanent institutions of mankind a family is a group of people united by the ties of marriage blood or adoption constituting a single household and interacting with each other in their respective social positions usually those of spouses parents children and siblings family is a very essential part of everyones life the importance of family has been inscribed in our brains since childhood the bond that we share with each and every individual in our family not only creates a respectful relationship but also transforms a house into a home family is a universal group a family is based on marriage which results in a mating relationship between two adults of opposite sexes family is the most important group in any individuals life family is the most basic and important group in the primary socialization of an individual family is based on emotions and sentiments mating procreation maternal and fraternal devotion love and affection are the basis of family ties the family is a unit of emotional and economic cooperation family is a great source of strength both emotional and psychological for its members all the members are aware that they can depend on their family in times of need the family is the basis of the division of labor where all members have their duties and obligations towards each other a family fulfills the economic needs of its members a husband and wife are lifelong companions who lead a common life they are two intimate comrades the rights and status of each are equal they should work together and manage household affairs together they should encourage and help each other in all social activities in daily life they should take care of each other and show consideration as for their parents both sides should bear the responsibility for their care this kind of relationship between husband and wife will continuously increase the feelings between the two and make their lives more and more ideal the husbandwife relationship is most important in the lives of people it is crucial for longlasting happiness in our lives has studied the relationship between marital adjustment and depression among couples the sample of the study consisted of 26 couples their ages ranged from 25 to 50 years their education was at least gradation and above they belong to middle and high socioeconomic status results indicated a highly significant relationship between marital adjustment and depression the findings of the results also show that both women and men have to face more problems in their married lives conducted a study among married women and men the study aimed at finding the relationship between empathy forgiveness and marital adjustment the study reported that higher levels of empathy have a positive relationship with marital adjustment there were significant gender differences between males and females in the domains of empathy and forgiveness in a marital relationship review of literature conducted a study to investigate the effect of demographic variables on the dyadic adjustment and interpersonal behavior of married individuals and the role of interpersonal needs on the dyadic adjustment of married individuals married individuals living in a nuclear family or joint family preferred social interactions and enjoyed the company of others but the structure of the family alone might not influence the extent of social interactions there might be some personality factors situational factors personal preferences and so on there was a statistically significant effect of demographic variables on the interpersonal needs of married individuals studied the marital adjustment of married couples marital adjustment with regards to love marriage and arranged marriage and the interactive effect of marital adjustment with regards to gender and type of marriage the study found that there was no significant difference in the mean score of marital adjustment among the married males and females there was no significant difference in the mean score of marital adjustment among the couples of love marriage and arranged marriage and there was no significant difference in the interactive effect of the mean scores of marital adjustment with regards to the gender and type of marriage conducted a case study to understand the interpersonal relationships and communication among married couples the study concludes that the relationship between husband and wife resembles the relationship as a friend or an enemy giving colors to the relationship in the early years of marriage the husband often facilitates the role of parent in dealing with wives and the adultadult relationship pattern develops as they share their business duties the present study aims to find out perception of married women about family life satisfaction in nallagoundanpatty village panchayat of omalur taluk in salem district of tamil nadu methodology the present study has been carried out in nallagoundanpatti villiage panchayat and nallagoundnpatti is located in omalure taluk of salem district and which is 16 km far away from the headquarters of salem and 326 km from state capital chennai nallagoundanpatti is surrounded by salem block towards east taramangalam block towards west kadaiyampatty block north mecheri block towards west the married women who are above the age of 20 years in nallagoundampatti village panchayat considered as universe of the present study and with the help of purposive sampling the researchers identified 30 respondents in the study area a structured interview schedule has been used as a tool of data collection and which consists of socioeconomic conditions of the respondents and questions related to family life satisfaction the socioeconomic conditions have assessed with age education occupation monthly income type of family and husbands particulars whereas the family life satisfaction have been measured with seven statements and the respondents responses were recorded on a fourpoint scale viz always sometimes often and never the scores assigned for these fourpoint measurement of the respondents responses were 4 for always 3 for sometimes 2 for often and 1 for never for positive statements and reverse score pattern have been followed for negative statements the collected data were analyzed with the help of simple frequency table and percentile score results and discussion the age of the respondents is considered 234 per cent of the respondents were aged between 2030 years 433 per cent were aged between 31 40 years 133 per cent of the respondents were aged between 41 50 years and remaining 20 per cent of them were aged 51 and above with regard to education 624 per cent of the respondents were completed their school education 273 per cent of the respondents were graduates 24 per cent of the respondents were post graduates and remaining 79 per cent of the respondents were illiterates while considering the occupation of the respondents 833 per cent of the respondents were housewives 167 per cent of the respondents were agricultural workers as per as the occupation of the respondents husband is considered 40 per cent of the respondents husbands were farmers 333 per cent of the respondents mentioned that their husbands were masons 20 per cent of them revealed that their husbands were doing business and 667 per cent of the respondents husband were labourers of private companies the monthly income of the families is concerned 30 per cent of the respondents were mentioned that their family monthly income was between rs10000rs15000 467 per cent of the respondents were revealed that their family monthly was between rs15000and rs20000and remaining 243 per cent of the respondents were stated that their family monthly income was more than 20000 the marital longevity of the respondents is considered that 286 per cent of the respondents have more than 21 years of marital longevity 262 per cent of the respondents have 11 20years 238 percent of the respondents have 5 10 years and 214 percent of the respondents have less than 5 years of marital longevity with regard to type of marriage 595 of the respondents mentioned that their marriage was arranged marriage 286percentof the respondents revealed that their marriage was love marriage and remaining 119 per cent of the respondents stated that their marriage was love cum arranged marriage the table shows that the respondents responses on the statement my partneris sincere and practices what he preaches and responses revealed that 8667 per cent of the respondents mentioned that their husband always practice what he preaches 10 per cent of the respondents revealed that sometimes only their husbands follow what he preaches and remaining 333 per cent of the respondents stated that their husbands never practice what he preaches in the patriarchal society the husband is the head of the family and others are his followers and in such a set up when the head is needed that others must obey his words first he must follow what is he preaches to others but in the present study 1333 per cent of the respondents mentioned that either sometimes or never their husbands practice what he preaches and this type of situation prevails for a long period of time then the same may be the one of the reasons for the family disorganization the respondents are asked to respond the statement my partner is honest mainly because of a fear of being caught 80 per cent of the respondents replied that their husbands always honest but not because of a fear of being caught 1667 per cent of the respondents mentioned that their husbands often have fear of being caught because of this they are honest and remaining 333 per cent of the respondents revealed that their husbands sometimes have fear of being caught because of this they are honest a persons honest must be inbuild nature then only the same person should be receive respect from others and if a person is having his honest because of fear of being caught red handed then the same person should not receive respect from others in the present study one fifth of the respondents stated that their husbands have honest because of fear of being caught red handed and because of the welfare of the family this type of mentality must be avoided and such avoidance might help the family to function smoothly without any quarrels and controversies the respondents responses of the statement the advice my partner gives cannot be regarded as being trustworthy indicates that 8333 per cent of the respondents mentioned that they never treated their partners advice as untrustworthy 1333 per cent of the respondents revealed that they often considered their partners advice as untrustworthy and remaining 333 per cent of the respondents stated that they sometimes contemplated their partners advice as untrustworthy for smooth functioning of the family the members in the family should trust on one another and that type of mentality keeps family happy and everyone work hard for the welfare of the others and such mutuality contribute positively to the growth of the family and such family should earn name and fame in the society in the present study nearly onefifth of the respondents revealed that either often or sometimes they untrustworthy of their husbands the above table shows the responses of the respondents on the statement in most ways my family life is close to ideal 8333 per cent of the respondents mentioned that their family life is always close to ideal and remaining 1667 per cent of the respondents stated that their family life sometimes only close to ideal like the previous statement in this statement also 8333 per cent of the respondents stated their family life is close to ideal and others are responded negatively the similar percentage of the respondents responded negatively to the earlier statement and they mentioned that they do not trust their husband advice and this might be the reason for the respondents to mention that their life is not close to ideal the above table indicates the response of the respondents on the statement i am satisfied with my family life 8667 per cent of the respondents revealed that they always satisfied with their family life 10 per cent of the respondents stated that sometime only they satisfied with their family life and remaining 333 per cent of the mentioned that they satisfied their family life very often only since these much percentage of the respondents responded negatively to earlier statements viz family life is very close to ideal and partner is trustworthy and that might be the reasons for the present statement i am satisfied with my family life the respondents also asked about to respond the statement how well does your partner meet your needs 7667 per cent of the respondents revealed that their partner always meet the needs of the respondents 20 per cent of the respondents mentioned that their partner sometime only fulfill the needs of the respondents and remaining 333 per cent of the respondents stated that their partner never meet the needs of the respondents meeting the needs of the life partner is considered as one of the essential elements for the smooth and successful functioning of the family but in the present study more than onefifth of the respondents stated either sometimes or never their partner meet their needs and this must be corrected by the concerned family members sit together by making dialogue with one another in cordial and amiable manner and such dialogue might solve these type of family problems in successful way the data given in the above table indicates the responses of the respondents on the statement how good is your relationship compared most 8333 per cent of the respondents mentioned that their relationship is good always 1333 per cent of the respondents revealed that their relationship is good sometimes and remaining 333 per cent of the respondents stated that their relationship is never good the respondents responses indicate that nearly onefifth of the respondents mentioned that their relationship is either sometimes good or never good since these respondents earlier mentioned that they dont have life is ideal their partners doesnt meet needs and partners advice cannot be trustworthy the responses of the respondents on these statements might influence them to respond in such a way conclusion the present study has been conducted in nallagoundanpatti village panchayat in omalur taluk of salem district in order to know the family life satisfaction among the married women and in order to get the responses from the respondents 30 married women have been selected with the help of purposive sampling and their responses were recorded in the semi structured interview schedule the interview schedule consist personal information of the respondents and their responses over the family life satisfaction and the family life satisfaction have been measured with seven statements and these seven statements have been measured with four point scale simple frequency table and percentile score have been used for data analysis the data indicates that the mean age of the respondents work out 3579 years with a standard deviation of 425 the mean years of schooling was worked out 682 years with a standard deviation of 213 the mean years of marital longevity was worked out to 1237 years with a standard deviation of 269 with regard to respondents responses on the statement my partner is sincere and practices what heshe preaches 1333 per cent of the respondents responded negatively 20 per cent of the respondents responded positively to the statement my partner is honest mainly because of a fear of being caught 1667 per cent of the respondents positively responded to the statement the advice of my partner gives cannot be regarded as being trustworthy 1667 per cent of the respondents negatively responded to the statement in most ways my family life is close to ideal 1333 per cent of the respondents negatively responded to the statement i am satisfied with my family life 2333 per cent of the respondents negatively responded to the statement how well does your partner meet your needs and 1667 per cent of the respondents negatively responded to the statement how good is your relationship compared to most from the above observation it can be concluded that more or less onesixth of the respondents have had negative experiences over their family life and these types of dissatisfaction can be rectified immediately through proper family discussion along with family elders because the family elders ie the parents as well as the inlaws visit frequently and have had healthy discussion with their daughters as well as their soninlaws and such discussion help the couples to reveal their problems and issues and such platform enable all of them to sort out their misunderstanding in an amicable manner this type of frequent meeting also enable the couple to further strengthening their family life and such mutual coordination and consultation definitely bring the allround development to the entire family and then they will enjoy the fruits of cooperation if the couple fails to have frequent healthy discussion about their family affairs with their parents and inlaws then it will bring more dissatisfaction and such dissatisfaction ultimately leads to family disorganization the present study has been carried out in the rural setting and maximum all the people believe that families in the rural setting lead almost healthy as well satisfied family life but the results of the present study indicate that families in the rural setting also have some issues and misunderstandings and these could be rectified through appropriate measures the results of the present study consistent with the earlier study and it was found that nearly 25 to 40 per cent of the dual carrier married women have had responded negatively to the various statement of the life satisfaction mentioned that life satisfaction is influence with various factors like people where they live with finding happiness in little things financial security positive individual identity high selfesteem coping strategies with life stressors and positive thought process limitations the present study has been conducted with a sample of thirty married women and that too the sample selected from one village panchayat in order to generalize the results of the present study then it requires large sample size and that too cover wide geographical area author details c gobalakrishnan associate professor and head ic department of sociology periyar university salem tamil nadu india email id student department of sociology periyar university salem tamil nadu india k nivetha post graduate

family is the one of the prime as well as important institutions of the society when two or more generation lives together through the institution of marriage then such living together is called as family when family consists of two generations then it is called as nuclear family and when more than two generations lives together then it is called as joint family the style of living together always depends on mutual love and affection between the couples as well as others in the family and such type of family environment brings family life satisfaction among the member of the concerned family such healthy family environment helps the concerned family to progress and shine well in the society the present study has been conducted in nallagoundanpatti village panchayat in omalur taluk of salem district in order to know the family life satisfaction among the married women and in order to get the responses from the respondents 30 married women have been selected with the help of purposive sampling and their responses were recorded in the semi structured interview schedule the interview schedule consist personal information of the respondents and their responses over the family life satisfaction and the family life satisfaction have been measured with seven statements and these seven statements have been measured with four point scale simple frequency table and percentile score have been used for data analysis the results of the present study indicate that families in the rural setting also have some issues and misunderstandings and these could be rectified through appropriate measures

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background lower urinary tract symptoms are common among men worldwide and despite often being of benign origin they are associated with decreased quality of life 1 the prevalence among men is estimated to 4095 2 3 4 5 and increases with age 2 the large variation is presumably due to different definitions methods and study populations luts include various urological symptoms and can be classified into three subgroups storage voiding and post micturition symptoms 6 these symptoms are often perceived as a normal part of ageing which might prevent individuals from consulting their general practitioner 78 benign prostate hyperplasia is the most common cause of luts but several other conditions can cause luts including weakness of the detrusor muscle urinary tract infection overactive bladder and prostate cancer 6 the majority of causes are benign and thus not lifethreatening but distressing with the potential of causing psychological effects and exacerbating feelings of social isolation 7 medical examination is essential to initiate an intervention that can possibly alleviate the symptoms although several treatments are effective in reducing luts 9 the majority of men manage their luts in private settings 3 and thus the symptoms presented to gps are only the tip of the symptom iceberg 10 this could partly be explained by the fact that not all men are bothered by these symptoms hence it is understandable that they do not consult the gp a possible explanation for nonattendance to the gp is that men are unaware of the availability of medical treatment and thus they should be encouraged to consult their physician if they have bothersome symptoms 11 a study from 2004 has shown that advice from a persons social network increased the likelihood of contacting the gp with healthrelated inquiries approximately fivefold 12 in the study based on data from general practice 25 of men received advice prior to an appointment with their gp spousepartner was the most frequent person to give advice but was not significantly superior to other people from the social network that was defined as family friends colleagues neighbours home helps and district nurses 12 the decision to contact the gp is not simply based on the presence or absence of symptoms but is affected by multiple factors seeking help and deciding with whom symptoms should be discussed is thought to be based on a complicated decisionmaking process 13 when analysing healthcare seeking regarding symptoms in general we have previously found that people without an available social network overall were more likely to involve the gp compared to those with an available social network 14 so perhaps feeling socially isolated increases the chances of individuals visiting their gp as a way to receive muchneeded social connection 1516 based on this we hypothesized that men without an available social network were more likely to involve the gp regarding their luts compared to those with an available social network the aim of this study was 1 to identify the personal and professional relations involved by danish men bothered by luts 2 to analyse factors associated with involvement of personal and professional relations and 3 to analyse how access to a social network influenced healthcare seeking with bothersome luts method study design and population this populationbased crosssectional study is based on data from the danish symptom cohort a nationwide cohort comprising a random sample of 100000 people aged 20 years or above who are representative of the adult danish population all danish citizens are registered with a unique personal identification number in the danish civil registration system which contains information on date of birth gender etc 17 invitees were randomly selected from the general population through the crs and invited to participate in the survey by a letter explaining the purpose of the study the letter included a unique login to a secure web page which provided access to a comprehensive questionnaire after 2 weeks a reminding letter was sent to nonrespondents and after additional 2 weeks nonrespondents were contacted by telephone and encouraged to participate a telephone interview conducted by trained interviewers was offered to prevent the exclusion of people with no internet access data were collected from june to december 2012 and the methodological framework for developing and testing the questionnaire has been thoroughly described by rasmussen et al 18 in this study only male respondents were included questionnaire symptom related questions the questionnaire contained 44 predefined symptoms and six of these were related to luts in men and included in the present study five of the six symptoms were related to storage and one was related to voiding the questions regarding symptom experiences were phrased have you experienced any of the following bodily sensations symptoms or discomforts within the past four weeks it was possible to report more than one symptom and for each reported symptom the respondents were asked to provide additional information about who they had talked to regarding the symptom and to what degree the symptom had been concerning and influencing their daily activities a fivepoint likert scale was used as response option for the concern and influence on daily activities not at all slightly moderate quite a bit and extremely for each symptom reported the respondents were subsequently asked whether they had contacted their gp with the symptom or discomfort in person by phone or by email additionally respondents were asked which other healthcare professionals they had contacted with the options being another doctor physiotherapist chiropractor home helpdistrict nurse pharmacy staff alternative therapist none and other category furthermore they were asked which personal relations they had talked to regarding the symptom with the options being spousepartner children parents colleagueclassmate friend neighbour none and other category more than one relation could be selected generic questions on social network to examine whether the respondents had an available social network four items were used 1 how often are you in contact with friends acquaintances or family that you do not live with contact indicates that you are together talking with each other on the phone writing to each other etc with the response options being daily or almost daily once or twice a week once or several times a month less than once a month never i dont know 2 if you become ill and need help with practical things can you count on help from others others means people you do not live with with the response options being yes definitely yes maybe no 3 does it ever happen that you are alone even if you want to be in the company of others with the response options being yes often yes once in a while yes but rarely no 4 do you have someone to talk to if you have problems or need support with the response options being yes often yes mostly yes sometimes no never or almost never data analysis the dataset for this study comprises men with bothersome luts defined as being of moderate to extreme concern andor with moderate to extreme influence on daily activities this means that symptoms reported as being of no or slight concern andor with no or slight influence of daily activity were not included in the analyses for further details of the distribution of bothersome luts see rubach et al 19 the study population included respondents who had answered all relevant questions basic descriptive analysis was used to study the involvement of each personal and professional relation when experiencing each of the following six symptoms frequent urination nocturia stress incontinence urge incontinence incontinence without urgestress and difficulty emptying the bladder subsequently the three incontinence symptoms were merged into one symptom category named incontinence giving a total of four luts the merge was due to few observations in each symptom group and the category included the incontinence symptoms if any of the three incontinence symptoms were reported as bothersome the study sample was stratified into four age groups 40 years 4059 years 6079 years and ≥ 80 years regarding the available social network individuals were categorized as having no available social network if all the following responses were chosen neverless than once a month being in contact with others having no available individuals who can help often being alone when desiring to be with others and neveralmost never having a person to talk to in case of problems we used multivariate logistic regression models to analyse possible associations between involvement of personal and professional relations and specific characteristics crude and adjusted odd ratios were calculated adjustments were made for possible confounders age number of symptoms and available social network for the logistic regression analyses we categorized the personal and professional relations into five groups 1 the gp 2 another doctor 3 other healthcare professionals 4 family members and 5 personal relations other than family other healthcare professionals comprised all professional relations selectable apart from the gp and another doctor family members included spousepartner parents and children and personal relations other than family encompassed colleagueclassmate friend neighbour and others all data analyses were conducted using stata 131 and a significance level of p 005 was used results of the 48910 randomly selected men 46647 were found eligible for the study and 23240 participated yielding a response rate of 498 the majority completed the questionnaire online a total of 22297 men had answered all relevant questions regarding involvement of personal and professional relations and available social network of those 4885 men reported at least one bothersome luts and were included in this study baseline characteristics differed among respondents and nonrespondents the median age among respondents was 53 years compared to 48 years among nonrespondents more respondents were marriedliving together had a high level of education high income and were more often working compared to nonrespondents 10 overall the prevalence of luts varied from 41 for bothersome incontinence to 17 for bothersome nocturia the proportion of men who did not involve neither personal nor professional relations varied between 213 and 273 for nocturia and difficulty emptying the bladder respectively when a relation was involved it was most frequently a personal relation mainly the spousepartner friend and children regarding all four luts among professional relations the gp and another doctor were the most frequently involved regarding all bothersome luts however more than half of the men with symptoms frequent urination nocturia overall incontinence did not seek advice from a professional relation involvement of personal and professional relations among men experiencing at least one bothersome luts stratified according to age groups is shown in table 2 overall 235 of men experiencing at least one bothersome luts involved neither personal nor professional relations and 591 involved no professional relation at all men 40 years of age were more likely not to involve any relation than men 80 years of age among men 40 years of age 137 involved the gp regarding their symptom compared to 44 among men 80 years of age a similar pattern for involving another doctor was found no involvement of any professional relation was reported more often among men 40 years of age compared to men aged 80 years or above the odds of involving the gp another doctor other healthcare professionals family members and other personal relations regarding each of the covariates are shown in tables 34 5 6 the odds of involving the gp were statistically significantly higher in the oldest age group for frequent urination nocturia and difficulty emptying the bladder but not for incontinence similarly the odds for involving another doctor was statistically significantly higher among men 60 years of age compared to those 40 years of age for all symptoms except for incontinence the odds of involving a family member were higher in the oldest age groups for difficulty emptying the bladder the same pattern was found for frequent urination although not statistically significant for the group 80 years report of increasing number of bothersome luts was statistically significantly associated with increased odds of involving the gp and another doctor for nocturia the same tendency was found for the three other luts however only significant for 4 symptoms or 3 symptoms involvement of personal relations was statistically significantly associated with a two to fourfold increased odds of involving the gp another doctor and other healthcare professionals for all four bothersome luts having an available social network was significantly associated with lower odds of involving the gp with frequent urination although not statistically significant the same tendency was seen for the remaining symptoms for frequent urination and incontinence men with no available social network were more likely to involve a personal relation other than family discussion article summary this populationbased study comprised 22297 randomly selected men from the general population and of those 4885 reported at least one bothersome luts yielding a prevalence of 219 among men experiencing bothersome none indicates that neither personal nor professional relations were involved regarding the symptom luts 235 involved neither professional nor personal relations regarding their symptom involvement of personal relations was most common and was associated with a two to fourfold increased odds of involving the gp another doctor and other healthcare professionals the most frequently involved professional relation was the gp followed by another doctor and the odds of involving either of these were highest among the oldest group of men men categorised as having no available social network had higher odds of involving the gp and other healthcare professionals regarding frequent urination for the remaining luts a similar tendency was observed however not statistically significant strengths and limitations of this study this study was a large nationwide crosssectional study including 22297 male respondents to our knowledge such a large populationbased study has not previously been conducted concerning personalprofessional relations and network activation among men with bothersome luts however the crosssectional nature of the study is a limitation longitudinal data would allow the temporal sequence of variables to be established more stronglythe response rate of 498 was consistent with previous studies 320 however it is unknown whether individuals experience symptoms are less or more inclined to participate in the study and thus an underestimation or overestimation of the prevalence cannot be eliminated the webbased questionnaire was not available in a paper version which may have prevented some invitees from participating in the study especially the elderly the possible selection bias was minimized by offering the possibility of conducting the survey as a telephone interview to people with no internet access the random selection through crs was also used to eliminate the risk of selection bias information on the symptom experiences and who the respondents involved regarding their symptoms were selfreported and since luts might be associated with shame and embarrassment 11 it is possible that an underestimation of the prevalence of luts is present however the underestimation is presumably minimized by the webbased design because of an increased personal relations other than family encompass colleagueclassmate friend neighbor and other adjustments were made for possible confounders age number of symptoms available social network perception of anonymity the invitees were asked to recall symptom experiences within the preceding 4 weeks and whether they had talked to a personal or professional relation regarding these symptoms at any time the 4 weeks recall period was used to obtain statistically precise estimates while still assuming the participants could recall symptoms accurately however recall bias cannot completely be eliminated in questionnaire studies some may have forgotten to report a symptom or a relation they had involved because the symptom experience turned out to be inconsequential or simply due to memory decay others might have misplaced symptom experiences outside the timeframe of the study due to severity of the symptoms or because they had already involved a personalprofessional relation about them as only individuals bothered by luts are included we believe that this risk of recall bias is negligible 21 to obtain further information about the symptom disclosure more response options could have been presented for instance the use of social media or the internet might have been a frequent reason not to contact the gp among the young respondents this paper investigates bothersome luts which were defined as being of moderate to extreme concern or influence this definition was chosen because luts often are of benign origin and therefore it might be unnecessary for men with no bother from their symptoms to seek medical attention the term bothersome was a construction made in the author group based on the literature and clinical experience and is described more in detail elsewhere 19 this construction however still needs further validation in the population to be defined as bothered respondents could be either moderate to extremely influenced by the symptoms without being concerned or vice versa it may have influenced the results that respondents categorised as bothered by luts could be moderate to extremely influenced by the symptoms without being concerned or vice versa a diagram of the distribution of bothersome is shown in rubach et al 19 and it reveals that more than half of the symptoms were of both moderateextreme influence and moderateextreme concern it is plausible that men being both extremely concerned and extremely influenced by luts are more likely to involve professional or personal relations compared to men being moderately influenced in their activities but with no or little concern whether influence or concern is the greater driver for involvement of others is yet to be determined we hypothesized that involving a personal relation may influence the decision to seek healthcare with bothersome luts however the questionnaire did not give any information about the chronological order in which the relations were involved therefore we can only describe whether a relation was activated or not furthermore the study did not reveal the quality or content of the contacts made and thus it is unknown whether a potential advice from the personal network is in favour of helpseeking or not if the advice from the personal network is inadequate it may prevent the patient from contacting the gp and thus delay medical evaluation we intended to analyse the impact of having an available functional network on the helpseeking process and therefore presumed that individuals having contact less than once a month and almost never having a person to talk to had a very sparse network in the dichotomized analyses they were therefore categorized as having no available network comparison with existing literature around onethird of luts were discussed with the gp in this study which is lower compared to a study by pescosolido who found that the gp was involved in 854 of the illness episodes registered in a retrospective survey 13 the high involvement of the gp in the study by pescosolido was expected due to the way illness episodes were selected we found that a minority of symptoms are discussed with the gp which is in concordance with previous studies 1020 most luts are of benign origin and therefore treatment should primarily be targeted men with bothersome symptoms as our survey was conducted in a gatekeeper system with free access to the gp a high utilization of the gp was expected among our study population however more than half of men experiencing bothersome luts had not involved any professional relation in comparison a populationbased study by boyle et al 22 found that 409775 of men with bothersome incontinence involved a doctor regarding their symptom which is higher compared to our results boyle et al 22 had a different study population of men aged 4079 years compared to this study where men above 20 years were included in boyle et al 22 bothersome is defined based on the impact on daily life by using the bph impact index whereas this present study included symptoms being either concerning andor influencing everyday life further no timeframe for experiencing the symptoms was defined in the study by boyle et al norby et al 3 found that 92 of men 50 years of age with voiding problems had involved a doctor within the past 2 years which is lower than our findings for difficulty emptying the bladder and may be caused by the longer timeframe the different study populations and the severity classification further they found that elderly men involved the doctor more often than the younger men 3 this matches our study where a higher proportion of men above 80 years had involved the gp compared to men 40 years of age the more frequent involvement of the gp among elderly men could possibly be caused by the fact that elderly men consult their gp more often for other reasons which provides more opportunities to present the luts likewise the more frequent consultations could provide the elderly with a better relation to their gp and thus it could eliminate the shame and embarrassment associated with luts in addition younger men might be more likely to search the internet for advice instead of consulting the gp compared to the elderly surprisingly 779 of men 40 years of age with bothersome luts did not involve any professional relations various barriers to healthcare seeking among men in general have been suggested by yousaf et al 23 and might be part of the explanation for this finding yousaf et al found that there were several psychological and contextual factors discouraging men to seek medical help among these were embarrassment anxiety and fear along with lack of knowledge about symptoms treatments and services and viewing symptoms as minor and insignificant 23 furthermore poor communication and lack of time was mentioned as important factors for initiating medical contact 23 to what extent these factors affected our results is uncertain but nevertheless a possible explanation for the finding in the present study the spousepartner was the most frequent relation involved in general and was involved in more than half of all the cases friends and children followed the spousepartner as the most common personal relation involved these findings are supported by roe et al who found that spousepartner was most frequently involved followed by family and friends for patients with urinary incontinence 24 however a lower prevalence of involving personal relations was found by roe et al as 4749 had involved the spousepartner compared to 584676 in our study the involvement of a friend was 2532 in roe et al compared to 89113 in our study 24 roe et al included both men and women and the study were conducted in the uk which could be the explanation for the difference in the results we found that odds of involving the gp another doctor and other healthcare professionals were two to fourfold higher when a personal relation was involved the findings are comparable to the study by eriksson et al 12 who found that being advised by others to seek medical attention increased the likelihood of seeking primary healthcare approximately fivefold this might indicate that personal relations can act as a trigger of healthcare seeking in the present study men without an available social network more often involved the gp about frequent urination compared to men with an available social network similarly a paper with results from three studies showed that low social group connectedness was associated with a higher frequency of primary care attendance 15 in the present study men without a social network were more likely to involve a personal relation other than family compared to men with an available social network the explanation for this could be that men without an available social network disclose their symptoms to a neighbour or colleague whom they cannot rely on in case of illness furthermore it could indicate that family was interpreted as the available social network for most men conclusion this study found that despite the high prevalence of bothersome luts more than one fifth of men experiencing luts involved neither personal nor professional relations and more than half did not involve any professional relations the involvement of relations differed with age but overall gp and another doctor were most frequently involved among professional relations while spousepartner friend and children were preferred among personal relations involving personal relations was associated with higher odds of involving the gp another doctor and other healthcare professionals for all four luts among men with frequent urination having an available social network was associated with lower odds of involving the gp compared to not having an available social network this study delivers knowledge of symptom disclosure which is generalisable to other western cultureshealthcare professionals could use this knowledge to detect and treat men suffering from bothersome luts likewise this knowledge could be used in campaigns to inform the general population about the symptoms management and treatment options available for luts such campaigns should also address spousespartners as they were the most frequently involved personal relation and thereby they could help encourage the men being bothered by luts to seek medical help further the gp could use this information to take a more active approach when men consult them regarding other medical issues it could be relevant in future research to investigate the chronological order in which the relations are involved the quality of the relations and the characteristics of potential barriers to involve personal and professional relations moreover the use of online information sources and the social media could be further investigated availability of data and material the datasets generated and analysed during the current study are not publicly available due to the data protection regulations of the danish data protection statistics denmark and the danish health and medicines authority access to data is strictly limited to the researchers who have obtained permission for data processing this permission was giving to the research unit of general practice department of public health university of southern denmark abbreviations luts lower urinary tract symptoms gp general practitioner bph benign prostate hyperplasia crs civil registration system authors contributions kb ph dj and sr participated in the design of the study development of the questionnaire the logistics concerning the survey analyses and the drafting of the manuscript mk drafted the first version of the manuscript all authors read and approved the final manuscript competing interests the authors declare no competing interests

background lower urinary tract symptoms luts are common among men worldwide and despite frequently of benign origin the symptoms often influence quality of life most men experiencing luts manage their symptoms in private settings without consulting their general practitioner gp therefore the purpose of this study was to identify who in the personal and professional relations danish men discussed their bothersome luts with to analyse factors associated with discussing luts with personal and professional relations and to analyse how having a social network influenced healthcare seeking methods a nationwide populationbased crosssectional survey representative of the danish population a total of 46 647 randomly selected men aged 20 were invited to participate data were collected in 2012 the main outcome measures were odds ratios between involvement of personal and professional relations gp contact and different characteristics age number of symptoms available social network and involvement of personal relations among men experiencing bothersome luts we used multivariate logistic regression models results overall 22297 men completed the questionnaire of those 4885 219 had experienced at least one luts 235 had not discussed their symptoms with either personal nor professional relations and 591 had not discussed their luts with any professional relation the symptoms were most often discussed with personal relations primarily the spouse partner who was involved in more than half of the cases odds of consulting the gp another doctor and other healthcare professionals were two to fourfold higher when the symptoms were discussed with a personal relation having an available social network was significantly associated with lower odds of consulting the gp regarding frequent urination conclusions despite the high prevalence of bothersome luts more than onefifth of men did not discuss their symptoms with either personal nor professional relations and more than half did not discuss the symptoms with any professional relations discussing the symptoms with personal relations was generally associated with higher odds of seeking professional help and for frequent urination having an available social network was associated with lower odds of consulting the gp the results may be useful for detecting and treating men bothered by luts

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introduction in 2015 the world health organization reported that over 11 billion people smoked tobacco with males using tobacco products more than females the prevalence of tobacco smoking appears to be increasing in the eastern mediterranean region and the african region in jordan the percentage of tobacco smokers is one of the highest in the world reaching 702 among males looking at these percentages jordan adopted the national tobacco control strategy for 20172019 which is based on the implementation of a comprehensive set of tobacco control measures approved by the who the strategy aims to diminish tobacco usage by 30 by 2025 the use of electronic cigarettes has become an alternative option for tobacco smoking according to the national cancer institute and the national institute on drug abuse ecig is defined as a batteryoperated device that people use to inhale an aerosol which typically contains nicotine flavorings and other chemicals ecig has been invented as a tobacco smoking cessation tool due to the common belief in its safety compared to tobacco smoking some studies suggested that ecig might be less harmful than tobacco smoking especially when people who regularly smoked tobacco switch to them as a therapeutic replacement however nicotine in any form is a highly addictive drug levine et al reported that ecig can even prime the brains reward system putting vapers at risk for addiction to other drugs in addition ecig use exposes the lungs to a variety of chemicals including added flavors to eliquids volatile organic compounds and some heavy metals such as nickel tin and lead which are produced during the heatingvaporizing process those chemicals have been found to induce inflammatory responses similar to those induced by tobacco smoking based on recent evidence exposure to the constituents of ecig aerosols might result in serious respiratory injuries and complications including asthma chronic obstructive pulmonary disease and severe inflammation of the lungs many research studies have been conducted to evaluate the beliefs and attitudes of people toward the ecig in egypt for example most of the healthcare providers believed that the ecig is unsafe and does not help in tobacco smoking cessation besides more than half of the healthcare providers and the general population agreed that using ecig is a public health concern in south east england a study aimed to explore how ecig is perceived by a group of ecig users found that ecig was used as a therapeutic aid to stop or cut down on tobacco smoking some users adopted the ecig as a hobby and a social activity additionally it was found that most ecig users opted to use ecig to improve their health in china about 88 of the study subjects were found aware of ecig especially the current tobacco smokers and exsmokers who had a higher level of awareness and use of ecig than others it is worth mentioning that the majority of ecig users perceived their health to be in a better state since they began to use it currently limited published data addressing ecig perceptions and usage among jordanians a population titled to become number one when it comes to smoking rates calls for an urgent investigation therefore this study was aimed to measure the prevalence of ecig usage among jordanian adults and to assess their knowledge beliefs and practice toward ecig use materials and methods study design and participants a crosssectional study was conducted between october and december 2019 a selfadministered electronic questionnaire was developed and validated to solicit anonymous responses from the study participants eligible participants included jordanian adults interested in participation participants were recruited online through social media platforms facebook twitter linkedin and whatsapp participants who were unable to open the questionnaire and asked to send them the questionnaire were contacted via their provided institutional emails the used invitation statement for sample recruitment was we are a group of keen researchers from different jordanian universities would like to invite you to fill this questionnaire which aims to measure the prevalence of electronic cigarette use among jordanian adults and to assess their knowledge beliefs and practice towards electronic cigarette the questionnaire consists of three sections only which will require 57 minutes of your time to answer knowing that the questionnaire does not require writing the name or any other private information the information will be treated in strict confidence and will be used for the purposes of scientific research a comprehensive description of the study was introduced on the first page of the questionnaire mentioning that the participation in the questionnaire is voluntary and their response would be treated confidentially potential participants who completed the survey were considered to have given informed consent for study participation questionnaire development the questionnaire was developed after reviewing validated surveys found in the literature and designed using the general principles of good survey design this online questionnaire was created using the technology of google forms provided by google™ the questionnaire contained multiplechoice questions that can be completed within 15 minutes and it was administered in arabic being the official language of the jordanian population this questionnaire contained three parts the first part was designed to collect data regarding participants sociodemographic characteristics part b was designed to evaluate the knowledge and beliefs about ecig and part c was prepared to assess the practice and attitude of jordanian adults toward ecig the questionnaire is available from the corresponding author upon request validation and reliability the initial draft of the questionnaire was evaluated by the research team members and amended to enhance the clarity and readability of the study questions the evaluation of validity and reliability of the questionnaire was conducted by a professional committee of clinical pharmacists and a statistician confirming the applicability for the jordanian population the questionnaire was translated from english to arabic and backtranslated by two senior academic staff members who were fluent in both languages the questions were free from medical jargons or hard terminology then the questionnaire was evaluated and validated via a pilot sample of 25 academics and 25 nonacademic participants during a month pilot study to ensure comprehension clarity readability and acceptability of the survey accordingly modifications to the questions were made as needed before its implementation the cronbachs alpha coefficient was tested for the study instrument which indicates the internal consistency and reliability measures sociodemographic the sociodemographic information including age gender educational level and work status was requested also in the case participants were tobacco smokers they were asked about their tobacco smoking history and the heaviness of their smoking beliefs toward the ecig participants were asked if they agreed or disagreed with certain questions related to their beliefs and attitudes toward the ecig questions focused on their beliefs toward the safety of the direct or passive vaping ecig compared to tobacco smoking participants were asked if they believed that the ecig was a helpful aid for tobacco smoking cessation and if they switched from tobacco smoking to the ecig before more questions were asked related to the impact of the ecig on the participants general health public health and its addictive potential finally this section included questions about participants beliefs toward the ecig cost and costeffectiveness uses in public areas and their selling regulations the options followed a likert scale including strongly agree agree neutral disagree strongly disagree as some participants 2 muna barakat et al may not have the needed knowledge about the ecig or the fact that it presents a health issue the option neutral was added as an option to the likert scale providing the participants with the needed response while answering such questions attitudes and knowledge toward ecig the participants were asked about their knowledge and attitude toward the ecig by specific questions the questions were about how they heard about the ecig for the first time if they ever tried using it before and if they were current solo or tobacco combined users accordingly participants were classified to be as never used the ecig and the ecig user who ceased its use and lastly the the current ecig user sample size the most recent demographic statistics belonging to citizens living in jordan showed that 10554 million people live in the country based on that the sample size was calculated using a margin of error of 5 confidence level of 95 and response distribution of 50 giving a minimum sample size of 385 it was decided to increase the number to around 995 to take into account missing responses and other unknown issues that might arise statistical analyses statistical analyses were conducted using the statistical package for the social sciences version 240 for windows descriptive statistics including percentages means and frequency distribution were calculated for each of the questions categorical variables expressed as a proportion were analyzed using the chisquare test descriptive and univariate correlation analyses with the pearson correlation coefficient was used for the correlation at the 5 significance level a pvalue of 005 represented a significant difference simple and multivariant linear logistic regression was used to explore significant correlations between the ecig use and different variables results sociodemographic characteristics out of the total 995 completed questionnaires 11 forms were excluded from the study due to being incompletely answered accordingly 984 of the answered questionnaires were included in the study analysis table 1 showed the demographic characteristics of the study participants among the total study sample more than half of the participants were females the participants had a wide age range almost onethird of the participants were aged 2635 years and 263 were aged 3650 years the majority of participants had a university degree either bachelors or postgraduates more than half of the participants were employed selfemployed and many were students about 50 were married and most of the participants lived in the capital of jordan amman as demonstrated the study participants were stratified for different categories out of the 326 participating ecig users half of them had replaced tobacco completely with ecig while the rest were either dual users for ecig and tobacco or ecig users without a tobacco smoking history statistically there was a significant difference between the subgroups over most demographic characteristic variables among the ecig users and tobacco smokers subgroups most of them were male aged between 26 and 35 years and had a bachelors degree most of them were married live in amman and were employed all the participating ecig users were vaping nicotinecontaining eliquids on the other hand tobacco smokers were varied in the heaviness of their smoking 211 of them were heavy smokers while 343 reported being moderate and the rest were lowgrade smokers as well most of them 657 were smoking tobacco for more than 5 years knowledge about the ecig almost all participants reported having heard previously about the ecig many stated that the main source of their knowledge about the ecig was from their personal contacts including friends and family followed by social media and media advertisements as for the reported level of knowledge about the ecig only 4 of the participants did not know anything about the ecig while about half of them reported a moderate level of knowledge beliefs toward ecig in general participants beliefs showed that the majority agreed that ecig usage is a public health concern and it should be regulated at work and in public places as is the case with tobacco smoking half of the study participants believed that ecig use is cheaper and costeffective compared to tobacco smoking furthermore around 60 of them agreed that the ecig can be a gateway for conventional tobacco smoking and it might lead to smoking addiction in more detail there were significant differences in the beliefs responses between the study subgroups noticeably the majority of ecig users have a positive belief toward the safety of direct or passive ecig vaping the impact of ecig on the general health and normal life activities in case of switching from tobacco smoking to ecig and the beneficial effect of ecig on smoking cessation while most of the other categories responded either negatively or neutrally with those aspects moreover among all the study subgroups the majority acknowledged the belief on the costeffectiveness of ecig compared to tobacco but it may encourage their users to smoke tobacco and leads to smoking addiction and its use should be regulated like any other tobacco products surprisingly the responses toward the belief ecig use is a public concern and need to be regulated at work and public areas were varied among the ecig users ranged from agree for the users who didnt have a smoking history to disagree for the users who replaced tobacco with ecig correlations between responses multivariant linear regression outcome showed a positive significant correlation between the usage of the ecig male gender being single in the social status and the level of participants reported knowledge besides the results showed the primary health care research development participants use of the ecig increased significantly in parallel to their positive beliefs toward its safety the ability of the ecig to function as a smoking cessation aid and its costeffectiveness so those findings declared that the jordanians usage of ecig is dependent on three factors which are beliefs toward its safety the knowledge about ecig and beliefs of costeffectiveness of ecig discussion worldwide tobacco smoking leads to more than 7 million deaths per year and more than 16 million reports for smokingrelated diseases in the united states of america recently the tobacco smoking rate among jordanians was reported as one of the highest rates in the world 2 1 1 0 9 chisquare test 4 muna barakat et al et al 2019 while ecig use is becoming more popular globally and specifically in jordan as a new smoking tool that is marketed as an alternative to conventional tobacco cigarettes this crosssectional study succeeded in assessing the perception of the jordanian population toward the ecig and evaluated their knowledge about it compared to traditional tobacco smoking a significant prevalence of ecig usage among jordanians was identified in this study with a moderate perception toward safety usage was shown to be affected by the level of knowledge perceived perception of safety and relative affordability positive opinion toward the use of the ecig as an aid for tobacco smoking cessation was also identified although advertising the ecig in jordan across the media is very limited in this study almost all of the participants had heard about the ecig previously mostly on a personal level this was higher than any other percentage reported in the literature previously for instance it was found in a study conducted in egypt in 2019 that 793 of the participants only were aware of the ecig another egyptian study conducted in 2016 revealed that only 575 of the participants knew about the ecig a study conducted in 2015 in new york city found that only 32 of the participants heard of the ecig before study conduct although the ecig was first introduced to the market in 2004 it only started to gain popularity worldwide in 2012 which justifies the above findings in 2011 the global adult tobacco survey revealed that around 42 of the jordanian population aged 15 years and above smoked tobacco in this study 41 of the participants revealing to be current tobacco smokersexsmokers it seems that the problem of tobacco smoking in jordan is not declining it is actually very high compared to the surrounding middle eastern countries the study also confirms the persistence of another fact stated in 2011 by the global adult tobacco survey which is male smokers being dominant in proportion compared to females the jordanian culture and higher acceptance of males public smoking versus females public smoking could be the justification for such findings in this study the dual ecig users declared the use of ecig interchangeably with tobacco such practice could be related to the situation and the place of smoking as many of them perceived ecig as safe acceptable to be used in public places and it is not a public concern as tobacco similar findings were reported in a study conducted in sydney where 27 of the study ecig users were daily tobacco smokers as well it was reported in 2016 that the prevalence of dual use of ecig with tobacco smoking in the usa was 546 on the contrary two studies conducted in egypt found that none of their study participants were dual ecig users acknowledging the source of information for healthhazardous substances is important most of the participants in this study reported friends to be their main source of information on the ecig followed by social media and media ads previous studies found similar findings where about half of the participants considered media advertisement as their main source of information on the ecig other studies revealed the internet television and friends to be different sources of information on the ecig 690 70 60 30 3210 for those who switched completely from tobacco smoking to ecigarette do you believe that there is a positive impact on their general health status and normal life activities 0000 et al 2013emery et al 2014martinezsanchez et al 2015 this unofficial source of information could be behind many of the misconceptions identified among the participants in this study the majority of the respondents in this study perceived the ecig to be safe and cheap to use and a good alternative to tobacco smoking in fact the majority of them started using it as a replacement for tobacco smoking believing that the ecig poses lower health risks compared to tobacco smoking although the safety of the ecig is still uncertain the majority of participants reported positive beliefs regarding the safety of direct or passive vaping of ecig compared to tobacco smoke these results were not surprising considering previous findings unveiling perceptions and use of the ecig among jordanian medical students showing similar results to this study in terms of beliefs toward the safety of the ecig and its use in addition aboelkheir et al conducted a study in egypt in 2016 found that onethird of participants believed that the ecig is less harmful compared to tobacco smoking and about 6 reported that the ecig is not harmful at all such conceptions could be due to the messages delivered via the local marketing strategies showing the advantage of using the ecig versus tobacco smoking in addition there are some shreds of evidence shows that ecig is significantly less harmful than tobacco smoking and at least as efficacious as nicotine replacement therapies for tobacco smoking cessation on the contrary this conception was not the same elsewhere as medical students in saudi arabia and minnesota measured their beliefs regarding ecig usage reported that 42 of the students did not consider the ecig as a helpful method for tobacco smoking cessation of noteworthy during august 2019 the centers for disease control and prevention reported many incidences of respiratory distress cases and injuries due to ecig use questioning the real safety used in the ecig marketing campaigns worldwide the cdc acknowledged that the lung problem associated with ecig use was caused by tetrahydrocannabinol in 2019 the government in jordan imposed a 200 tax on ecig vapes and paraphernalia in july 2020 jordan banned tobacco smoking and ecig usage in all indoor public places in jordan ecig is allowed legally but the jordan food and drug association has published new regulations in 2019 for tobacco products and the ecig as a starting point for its restricted usage 2019 this comes in line with the latest who statement urging governments to consider optimal regulation of the ecig products including where it is allowed to be vape remarkably more than half of the participants in this study thought that ecig use in public places is a health concern and believed strongly that it should be regulated like other tobacco products and should be regulated at work and public places as well it was also reported that if vaping was allowed in public places unlike traditional cigarettes that would encourage smokers to switch to ecig use moreover although tobacco smoking and vaping may look similar the uncertainty of the longterm safety of direct and passive vaping of the ecig still stands with all that said it is apparent that the government in jordan has taken serious steps to control the use of ecig and tobacco yet holding health awareness campaigns aiming to deliver clear scientific information tailored to the different age groups of ecig users is still urgently needed as well health education programs for the ecig handlers and vape shop workers on the emerging health issues which could promote their knowledge and help them to answer the customers questions properly to the best of our knowledge this is the first study to assess the perception of jordanian population about ecig use which could be a standpoint for the future studies which concerned about smoking behaviors and cessation aspect yet this study is not without limitations which should be taken into account when interpreting the results these include using a nonrandomized convenience sampling method which limits the generalizability of the results however nowadays in light of the published review the recruitment of a research sample using social media platforms is considered an efficient and costeffective method demographics of the jordanian population in 2019 shows that 529 of the population were males 603 holding bachelor university degree and 42 were living in amman as 263 of the jordanians were aged 2034 years old while the ages of 3549 and 5065 recorded 177 and 81 respectively comparing the general population demographics with the study sample showed evidence of skewness in the sample descriptive analysis of the skewness statistics showed that living in amman versus other countries was associated with high skewness this will limit the generalizability of study results over the jordanian population further studies are required to investigate the prevalence of ecig usage in other cities the number of tobacco smokers participates didnt match the high percentage of tobacco smoking rates in jordan mentioned in this would urge the need for further detailed studies targeting the tobacco smokers perceptions believes and perception toward ecig as well as the participants believe that ecig could be a successful tool to quit tobacco smoking under strict regulations future studies should investigate the extent of real success among users conclusion this study illustrated a significant prevalence of ecig usage among jordanians with a moderate perception toward safety and showed a need for restrictive regulations the usage level is substantially affected by the belief toward its safety level of knowledge and relative affordability of the ecig among the surveyed population this study showed a considerable level of positive opinion toward ecig use as a helpful aid for tobacco smoking cessation nonetheless there is a need for health awareness campaigns for the entire jordanian community and healthcare workers about ecig use emerging related health findings and how to promote tobacco smoking cessation

the rate of jordanian tobacco smokers has been reported to be one of the highest rates in the world the electronic cigarette ecig has become an option or an alternative to tobacco cigarette smoking this study was aimed to measure the perception of jordanian adults toward ecig use methods a crosssectional study design was used a selfadministered survey was developed and validated to solicit anonymous responses from the study participants a convenience sample n 984 was recruited electronically through social media platforms descriptive statistics and correlation analyses were completed using the statistical package for the social sciences spss results more than half of the participants 53 were females and almost all participants had heard about ecig 992 mainly from their friends 40 and social media 345 about half of the participants were nonsmokers and around onethird of them 331 were current ecig users the majority of the participating ecig users had replaced tobacco with ecig 564 all the ecig users reported positive beliefs toward the ecig as a safer alternative for tobacco smoking about 45 of participants believed that the ecig is helpful in tobacco smoking cessation but should be highly regulated conclusion this study illustrated a significant prevalence of ecig usage among jordanian adults ecig users perceived ecig as a safer and cheaper alternative to tobacco smoking and that it helps in tobacco smoking cessation however health awareness campaigns are needed for the entire jordanian community about ecig use related emerging health findings and how to promote tobacco smoking cessation

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introduction respect for autonomy or respect for persons has tended to be the leading principle of biomedical ethics or research ethics respectively this principle historically has its roots in the liberal moral and political tradition of the enlightenment in western europe within this tradition the ethical justification of actions or practices strongly depends on the free decisions of individuals ie an action or practice can only be ethically justified when undertaken without any coercive influence and entered by free and informed agreement while there have always been disagreements on the details all theories of autonomy agree on two essential conditions the first is liberty specifying the independence from controlling influences the second is agency referring to the capacity for intentional action 1 used in clinical ethics autonomy functions primarily to examine decisionmaking in health care and serves to identify actions that are protected by the rules of informed consent informed refusal truth telling and confidentiality 1 autonomybased approaches are strongly expressed in tom beauchamp and james childress classic text principles of biomedical ethics for clinical bioethics and for research ethics the influential belmont report 12 many criticisms of autonomybased bioethics have appeared over the past thirty years from a number of different angles such as feminism casuistry disability rights multiculturalism cultural studies and ethnography in this article we take a different approach by exploring what we will call the medical individualism that autonomybased bioethics largely assumes and by raising questions about the relevance and impact of autonomybased bioethics in developing countries especially in light of initiatives to build capacity in research sites and to ensure access to healthcare in resourcepoor settings this paper argues that the medical individualism underlying autonomybased bioethics renders the latter incapable of addressing some of the most pressing bioethical issues in resourcepoor settings which have to do with social justice the first section of this paper considers some of the limitations of principlism the second section examines the inability of this approach to address social justice concerns in resourcepoor countries finally the third section attempts to offer an alternative approach by exploring the contribution of the sociological model of disease causation to research ethics health justice and health policy a brief anatomy of autonomybased bioethics one of the major defenders of the centrality of autonomy in bioethics the british medical ethicist and pediatrician raanan gillon argues that respect for autonomy should hold a primary place among the four principles of biomedical ethics 3 other proponents of autonomy beauchamp and childress define autonomy as a form of personal liberty of action where the individual determines his or her own course of action in accordance with a plan chosen by himself or herself 1 in application to clinical medicine respect for autonomy dictates that patients with decisionmaking ability have a right to voice their medical treatment preferences and physicians have the concomitant duty to respect those preferences 4 like beauchamp and childress gillon embraces a millian understanding of autonomy understanding it as deliberated self rule the ability and tendency to think for oneself to make decisions for oneself about the way one wishes to lead ones life based on that thinking and then to enact those decisionsis what makes moralityany sort of moralitypossible 3 given its supreme ethical importance autonomy is not merely a value to be respected but a virtue or trait that ought to be actively developed nurtured and promoted according to gillon other ethical principles presuppose respect for autonomy beneficence and nonmaleficence toward autonomous moral agents presuppose respect for the autonomy of these agents even when they choose to refuse medical interventions which are lifesaving gillon also takes an autonomycentered approach to justice arguing that responding to peoples needs justly will require respect for those peoples autonomous views including autonomous rejection of offers to meet their needs and more importantly because providing for peoples needs requires resources including other peoples resources 3 to conclude his praise for autonomy gillon writes that respect for autonomy contingently builds in a prima facie moral requirement to respect both individual and cultural moral variability 3 while it is true that not all autonomybased approaches in bioethics take the explicit and extreme form expressed by gillon autonomy continues to be treated implicitly as a primary value in many controversial clinical and research debates from end of life issues to questions of exploitation of research subjects in international health research when ethical principles conflict it is often thought that the conflict can be resolved in an ideally impartial way by asking for example what the patient wants or whether the research subject really understood and freely consented to the procedures described in the research protocol in this way the multifarious values involved in the practice of medicine and biomedical research tend to be reduced to the principle of respect for persons itself narrowly understood as respect for autonomy furthermore the preeminence of autonomy as an ethical value within bioethics is deeply related to the increasing commoditization of medicine in developed countries for the more that medical practices are justified by reference to patient choice the more that patients will be viewed as clients and health care professionals perceived as service providers this model of patient as client which is prevalent in the united states of america and some parts of the western world assumes affluence and power the patient has to be capable of understanding and rationally weighing hisher optionspossibly even in disagreement with the physicianand be in a position to pay in exchange for services chosen autonomy exaggeration of human agency and ethical pluralism an autonomybased ethics places the responsibility for medical decisionmaking largely in the hands of the patient this raises the descriptive question of whether this conception accurately depicts how clinical decisions are actually made as well as the normative question about whether such a conception of responsibility should function as a universal ideal in regard to the descriptive issue patients in resourcepoor settings are often not concerned with their ability to determine and shape the course of cure their arrival at the local health center is the outcome of a long family discussion that led to the collection of money sometimes the patient arrives at the dispensary when the disease has reached its critical stage because the cost of care is too high the primary expectation of both patient and family is to get the medicine or undergo a medical procedure they need and go back to their workplace spending time at the hospital means loss of earnings for them and their families or the diminishment of financial resources when people can barely afford the cost of care or satisfy the nutritional requirements for a good recovery the ethics of medical encounter should be understood differently and expressed in different terms than patient choice instead of developing a highlyorganized medical bureaucracy that cares for the enforcement of patients rights and protects medical professionals from accusations of malpractice it would be more helpful to develop new sets of values that guide medical practice and promote patient participation in the healing relationship the framing of these values may encourage and foster a nonconfrontational relationship between health professionals and patients in the clinical setting and include social challenges that influence health in the bioethics agenda the role of bioethics will then consist in identifying social values and laws that may guide clinical work restore the social dimension of medicine connect the macrodeterminants of health to medical practice and health system delivery avoid the fragmentation of healthcare and advocate for good health policies the challenge facing bioethics in resourcepoor settings is not then to mislead people with unrealistic promises of autonomy that very few people can indeed achieve but to articulate moral principles and societal values that are oriented around the promotion of equitable access to care and which broaden the goals of medicine and public health the goals of medicine cannot be confined to the alleviation of suffering within the clinical setting medicine needs to be concerned with the determinants of good and bad health outside the clinical context in order to contribute to evidencebased clinical and public health interventions and education the major bioethical questions prevalent in resourcepoor countries do not essentially revolve around the provision of informed consent at the individual level but rather around the burning social questions of access to care commodification and quality of medical care the relationship between income disparities and health inequities the impact of poverty and underdevelopment on population health priorities in biomedical research and impacts of gender discrimination on womens health 56 once the focus is shifted away from the individualistic patient as client paradigm the social problems connected with the domination of medicine by market forces become apparent if the goal of medicine is to restore health functioning bioethics should avoid adopting a conception of autonomy that can be used to justify the domination of healthcare delivery by market forces alone and legitimizing health care systems that exclude the needy sick because the latter are unable to pay for services or afford hefty medical insurance premiums even those bioethicists who promote marketdriven medicine based on a libertarian anthropology 78 ought to carefully articulate alternative ethical values for health care and biomedical research if they not to be lured into a selfdefeating conception of medicine as an example of the latter tendency robert sade considers medicine as a market commodity and understands medical practice as sets of skills that physicians are entitled to sell on the marketplace to make as much money as possible even the cries of the destitute sick or government regulatory function cannot restrict the physicians appetite for greater financial reward sades anthropology and approach to medicine is based on the assumption that individuals have the right to select the values that they deem necessary to sustain ones own life they are also entitled to exercise their judgment to take the best course of action to achieve chosen values finally they have the right to dispose of those values once gained in any way one chooses without coercion by other men 7 similarly tristram engelhardt protects human freedom to the point of ignoring the fact that the concern that we have for each other makes life in society possible for him as long as freedom functions as a side constraint and as long as the moral community is based on respect for freedom and not force individual persons will have the possibility of holding entitlements 8 engelhardts suggestion is paradoxical because in trying to protect freedom of individuals to use their resources to access health care and other goods he does not ensure that those with few resources have the freedom to obtain health care realistically a genuine affirmation of autonomy cannot result in action informed or motivated by the desire to avoid being a responsible member of ones moral community 9 here responsibility means that one should not exploit others by using autonomy as a warrant to marketdriven medicine or profitseeking attitudes once medicine is understood as a commoditized product like any other those who cannot afford services are merely unfortunate consumers in this way a strong emphasis on autonomy can contribute to a culture in which healing and health promotion are no longer at the center of clinical practice and biomedical research one can hardly refute the fact that complex social and economic forces have placed patient autonomy at the center of medical ethics and thereby undermined the ageold ethic of physician beneficence 10 this change is sustained by waning trust in the traditional patientphysician relationship with the control of medicine by the forces of the market patients have become consumers of a market commodity called medical care as a result of this change the clinical relationship between the patient and physician begins to be seen as a contract and not as a covenant of care as it was in the past autonomybased bioethics has a tendency to distort the relationship between individuals and the world on the one hand it exaggerates the power and range of individual agency furthermore it underestimates the impact of society culture and environment both on individual decisionmaking and on health if persons are regarded as atomistic certain defensive notions of individualistic rightsbased autonomy prevail if a relational construction of personal identity is employed instead then respect for autonomy becomes part of a wider morality of relationship and care 1 atomistic autonomy is divisive and lacks social rootedness while relational autonomy brings about trust and communality the second version of autonomy which reveals our true self in society presents the possibility of placing trust and partnership at the center of the patientphysician relationship with such an understanding of personhood bioethics can better balance its concerns over choices and actions with those of relationship and responsibility a more plausible philosophical anthropology would conceive individuals as entangled in the world both capable of acting on it and subject to being affected by it reflection on the notion of disease both infectious and chronic can contribute to a more plausible philosophical anthropology for bioethics infectious diseases question our understanding of autonomous agency in two important ways first as both a victim and a vector a patient cannot be simply seen as a rational agent who has the final ethical word on his own decisions both vulnerability to infection and threat of transmission to others should shape our understanding of patient agency second the concept of choice that shapes our conception of agency in bioethics can no longer be understood in isolation from society risk of acquiring and transmitting infectious diseases reflects the patients interconnectedness with others and the biological environment an interconnectedness which is always there even when infectious disease is not present 11 although the values and desires of the patient obviously need to be considered the ideal of the autonomous agent will remain a fiction unless the social context of the patients vulnerability is also considered for other reasons chronic disease also challenges our understanding of autonomy especially when the patient finds it hard to manage his or her chronic condition family or friends stand as important resources for decisionmaking and longterm daily care for chronic diseases we should then recognize that the family and community which may play an important role in patient care are part of the resource needed by the patient to exercise agency 12 more and more it is becoming obvious that the promotion of patients agency requires serious consideration of patients best interests in a broader way against the backdrop of contemporary institutional medicine family solidarity is more important than ever to help maintain patients dignity and agency throughout stressful time 13 exclusion of family and relatives from the sphere of decisionmaking on account of respect for individual autonomy does not necessarily serve patients best interest furthermore primary care because of its focus on treatment and prevention of chronic and infectious diseases is the domain of medicine that goes beyond technomedical solutions to consider patients as persons with their stories relationships and social environment in which they live consequently primary care should essentially rely on sociallygrounded values rather than on desocialized principles 14 family and social relationships are important in the context of clinical medicine however we cannot undermine the importance of individual freedom we simply reject strong claims that do not have any social rootedness it would be almost unsound and socially untrue to radically endorse autonomy to the detriment of an ethic of responsibility and sociallybased care because they are mutually interdependent and a complete account of medicines moral axis requires that they be integrated this reorientation is crucial for reasserting the ethos of clinical medicine whose fundamental mandate remains the care of others 10 autonomy ethics and the moral vacuum for immanuel kant respect for persons never refers to the freedom to be left alone kants understanding of respect for autonomy provides the ground for the categorical imperative which he formulated in five different ways the third formulation act so that you treat humanity whether in your own person or in that of another always as an end and never as means only 15 cannot be reduced to the respect for autonomy often found in the bioethics literature the view of autonomy commonly found among individuals and in some of the bioethics literature in north america or western culture is more in tune with john stuart mills formulation of liberty do not intrude on the freedom of any person by an invasion foreign to his or her own wishes and values when kant talks about autonomy he does not imply that one should act according to ones own desires unconstrained by a balanced consideration of ones situation as a beingamongothers 9 instead he refers to the dignity of humans who are capable of making for themselves and others universal law hence autonomy rightly construed results in action informed and motivated by the desire to be responsible member of ones moral community 9 kantian autonomy is tied the moral agents search for the truth and respectable conduct the autonomous subject does not act in accordance to his or her primary inclination kantian autonomy is applied to actions performed when the will is freed from any selfish determination when humans treat each other as ends and never as means merely there arises a systematic union of rational beings under common objective laws physician and patient each with their own needs desires capabilities must find those principles that allow them to coalesce into a helping alliance to achieve a common goal contemporary readings often accept a millian version of autonomy that is associated with selfseeking attitudes this approach to respect for autonomy refers to the capacity to act on needs wants or wishes a capacity shared by many creatures since the persons action is informed by instrumental reasoning it constricts the scope of reason so that it is subject to any desire or disposition that one happens to endorse at the time one acts 9 focusing essentially on individual choices sets up a false and pernicious opposition between persons and the community to which they belong it is reasonable on both conceptual and empirical grounds to suppose that individuals acquire their values through engagement with a concrete moral tradition rather than through a private and selfdirected process instead of providing ethical decisionmaking with an objective and rational process the obsession with individual autonomy tends to create what mccormick calls a moral vacuum ie the disappearance of the network of shared and established goods and values that make the choices of individuals right or wrong moral or immoral 16 balancing autonomy and community in ethical decisionmaking it is hard to undermine the influence of social cultural and environmental factors on moral decision making we have to take these factors into account in order to fully appreciate the moral dilemmas and health challenges in settings and traditions where individualism does not prevail writing from their jewish background barthrogers and jotkowitz note that within jewish tradition the idea of unlimited human autonomy is not a defining value judaism deems the intrinsic human value of each individuals life to take precedence over patient autonomy 12 similarly the confucian culture from east asia understands the person not only as a rational autonomous being but also as a relational and altruistic entity whose selfactualization involves participating in and promoting the welfare of fellow persons 4 in the same line of thought african traditions present a view of the human person that is essentially relational it is within the social network that the individual lives and acts as a free person the jewish confucian and african cultures convey an understanding of the human person and society which is different from individualism operative in some cultures this is where the shortcomings of gillons autonomycentered conception of bioethics become the most obvious gillon does not reject the view that particular cultures should be respected instead he theorizes that the prima facie nature of autonomy requires that both the individual and cultural moral variability be respected 3 but this sense of respect for culture does not adequately reflect the social rootedness of the human person despite making concessions to culture gillon continues to view societal relationships determinants and influences to be peripheral to human reason and because of the danger of ethical relativism something to be transcended by a universal ethic hence the four principles can account for all our moral worries and being applied straightforwardly to all situations and contexts 17 gillon contends that any other moral principle or value can be explained by one or some combination of the four principles in fact however gillons quest for a universal discourse is nothing more than the promotion of one approach to ethics among others one which reflects specific cultural assumptions concerning individual choice and futureoriented action that are associated with class position and social opportunities and foreign to the lived reality of the poor the marginalized and people of color in a multicultural society like the united states 18 any attempt to universalize an ethnic particularity fails the test of respect for pluralism in bioethics and in our everglobalizing world in resourcepoor countries where medical paternalism prevails on account of patient beneficence and sharedresponsibility for health promotion 19 the necessity to create the conditions that improve for example patientphysician communication in ways that favor patient agency needs to be acknowledged very often the physician does not even tell the patient what is going on with his or her health however the onesided view of the human person which prevails in autonomybased bioethics should not be adopted as a model to correct paternalism a more fruitful alternative would be a combination between a communityand traditionoriented view and autonomy that conceives decisionmaking as guided by important human values such as partnership trust and solidarity in addition to autonomy this view would acknowledge the embedded and relational nature of human choices behavior ways of expressing emotions and feelings patterns of thinking and conceptions of disease and healing autonomy biomedical individualism and social justice some criticisms of autonomycentered bioethics have been purely conceptual others have emerged from reflections on its limitations in dealing with collective macroproblems including social sanitary and environmental problems that mark everyday life in poor countries autonomybased bioethics fails to engage the lived worlds of diversely constituted and situated social groups particularly those that are marginalized 18 similarly in clinical medicine broad issues such as the common good distributive justice and the spirituality of the patient are ignored for the sake of the primacy of secular business concerns to guide clinical practice laws have been developed to reduce risk for malpractice and protect patients however emphasis placed on the principle of autonomy has led to an excessive control of clinical practice by judicial institutions consequently this obsession with the law has led to the elimination of a wide range of moral concerns from public consideration 16 to emphasize this point mccormick criticizes clinical ethics for being preoccupied with cost control that focuses narrowly on matters of financial efficiency thus exiling the more basic ethical questions 16 furthermore any public health intervention that adopts the biomedical model fails to address issues of wider social injustices that are responsible for healthrelated vulnerability and risk autonomy ethics and medical individualism the biomedical model is premised on individualism because it adopts an abstract view of the body and mind of an individual person from a liberal model of economy and politics 20 in this model individuals choose health behaviors thus poor health is largely due to exposures to health risks that the individuals have decided not to avoid this approach to health risks disregards the role of social structures in structuring the array of risk factors that individuals are supposed to avoid 18 and fails to explain how social inequalities can be embodied in poorhealth outcomes 21 thus autonomyfocused bioethics rather than presenting an objective perspective deprives itself of theoretical tools to adequately address nonpathological causes of illhealth similarly in research sites much effort is often invested in securing the informed consent of individual participants while often ignoring the broader issues of justice in places where research takes place 22 consequently the absolutization of autonomy with the unreal and distorted picture of the person helps explain why so much bioethical writing is concerned with procedures that protect choice rather than more substantive issues with consent itself rather than what is consented to 16 this tendency to make the social causes of poor health invisible can even be seen among those working in public health to the extent that they subscribe to the biomedical model 20 biomedical model and the social gradient in health health differentials between individuals cannot be explained simply by their health behavior or lifestyles but also by their social position and economic status the social networks to which they belong and the levels of education that provide them with the means to avoid health risks deal with adversity and have access to lifeprotecting information the pervasiveness of the social gradient in health remains even when welldesigned public health interventions are implemented even when these public health interventions may reduce health risks and mortality they do not eliminate the social gradient because individuals in the lower socioeconomic groups take less advantage of health interventions than those who are better off when we compare the health statistics between poor and rich within countries or between countries the differentials are striking hivaids statistics provide us with striking examples of the impacts of socioeconomic status on risk differentials and chances of survival between groups within countries and between countries even in developed countries the geography of hiv aids challenges us to investigate the social causes of its distribution risks and survival differentials prompt us to consider a view that places politicaleconomic critiques of global resource distributions and criticism based on the higher and qualitatively different disease burdens in poor countries within a common framework of international and internal socioeconomic structure 23 at the local level income inequality in poor countries affects health and can be an indicator of life expectancy 2425 poverty affects individuals ability to have access to goods which are instrumental for wellbeing at the country level poverty limits governments ability to found social programs and provide people with basic social goods such as safe drinking water electricity good public health coverage healthcare institutions schools social services and economic opportunities these structural causes are steady and they include access to basic resources that can be used to avoid all sorts of health risks or reduce the negatives outcomes of diseases when they occur 26 most public health interventions focus on individual risk factors and behavior to lessen vulnerability and risk health professionals will need to address income differences between individuals and population groups otherwise they will only address the symptoms and not the rootcauses of poor health as public health practitioners and other health professions resocialize their conceptions of health and disease bioethicists should join and inform their efforts a sociological approach to disease can increase the social relevance of bioethics because it provides an acute perception of disease etiology and pathology that includes the social and material conditions in which people live sociological model and autonomybased bioethics to underscore the difference between western and nonwestern conception of illness bowman writes that most nonwestern cultures tend to perceive illness in a much broader and far less tangible manner illness is often viewed as being linked to social spiritual and environmental determinants 27 the sociological model of disease explanation shares some important connections with many nonwestern cultures in which disease representation and explanation is not primarily understood in biomedical terms but in social ones autonomybased bioethics is premised on the view that disease is located in the individual the focus on the individual person often reduces the scope of justice in clinical medicine and health research to an equal treatment of individuals involved and a fair distribution of available resources and burden regardless of peoples social status age race gender or religion in the clinics for example justice requires that patients whose circumstances are the same deserve the same level and quality of care conversely the sociological model perceives the disease as an integrated socialphysiological process which includes the persons relation to the environment in addition to its biophysiological dimension a disease is a relational phenomenon as a subjective and sociallyconstructed reality a disease develops out of the omnipresence of symptoms and bodily feelings in everyday life the sociological model allows us to develop a sociallyrelevant approach to health justice a new set of principles that may guide research as well as an approach to health policy based on the features of the site where research is done thus this model points to the fact that there are two reminders of our embeddedness in the world relevant to bioethics first biological embeddedness and infectious disease and second social embeddedness particularly in contexts where people are obviously dependent on one another and traditional behavior and customs are strong contribution of medical sociology sociological model and social justice the current formulation of ethical principles as they are applied to medical research in poor countries is inappropriate for capturing some crucial implications of medical research since they ignore the roots of health crises with which these countries are confronted 28 analyzing the health crises in african countries in the late 1980s the cameroonian sociologist jeanmarc ela argues that disease and malnutrition never exist by themselves rather they come from a system characterized by violence by a pattern of impoverishment of the majority and by the monopoly by a minority of the means to live with dignity 29 health interventions should not merely address the symptoms of a diseaseproducing society but also its structures social structures not only shape distribution of disease across population but they also determine societal and individual responses to suffering when the major determinants of health are far from being addressed by a conceptual framework that prioritizes individual problems and morality there is a need to call its relevance into question the high rates of infectious diseases in poor countries are linked to poor living conditions and structural problems these primary sources of exposure and vulnerability to health hazards should necessarily be considered in any attempt to develop bioethical standards for research or any bioethical agenda the poverty that permeates all spheres of society should be studied because poverty never exists in isolation from societal influences but rather is integrally a product of the inner workings of each societys political economy minimizing the contribution of poverty to the production of disease and disability in poor countries makes suffering invisible and limits our understanding of the etiology of disease medical sociology scrutinizes patterns of diseases and pathways through which social inequalities are embodied in individual vulnerabilities and major epidemics thus the model of disease causation that comes from sociological investigations challenges us to move beyond the clinics or research sites to broaden the scope of justice similarly the prevalence of infectious diseases in resourcepoor countries challenges the way justice is understood in research sites if we consider the patient as a potential victim and vector we need to shift our gaze from the healthcare that might be most desirable for the individual patient to broader social concerns and the worldview distribution of care that might enable all to achieve opportunities over a reasonable life span 11 the extension of care to all not only aims at serving individual needs for care but more importantly it addresses infectious diseases as a threat to population health opting out from an intervention of this kind would simply mean that the individual remains a threat to the entire population 3 the sociological explanation of disease incorporates a distinctive view of etiology prevention pathology treatment and justice this approach to disease explanation tacitly promotes a conception of responsibility for infection or disease causation which is not only individual this approach questions the uses of individualism as methodology and framework for analyzing disease occurrence and thus criticizes the onesidedness of the anthropology that sustains the biomedical model sociological model and justice in current biomedical research documents such as the declaration of helsinki issued by the world medical association and the international ethical guidelines for biomedical research involving human subjects as well as the work of the national council on bioethics in 2002 and that of the national bioethics advisory commission in 2001 all take material poverty as the main reason for developing bioethical standards that apply to medical research conducted in poor countries surprisingly the bioethics standards they promote hardly reflect the physical social and cultural environment of poor countries this is another important area for revision 28 given the substantial differences in individual exposure to health risks and the availability of health protective resources as well as differences in the disease burden and mortality and morbidity at the population level it is clear that illness in poor countries can be better understood using a social causation of illness perspective the principles of respect for persons beneficence and justice that shape the belmont report are all built on the biomedical model the principle of respect for persons reinforces individual agency and protection in the research setting by ensuring that participants are properly informed about the research or the course of care that will be taken to restore normal functioning the principle of beneficence extends the latter by insisting that research protocols should maximize potential benefits and minimize harm finally the principle of justice ensures that those with diminished autonomy are protected and that participants share in the benefits of the research agency benefit participation risk and vulnerability are all understood from the standpoint of the individuallyfocused disease management whether in the clinical setting or the research site to be of broader global significance ethical principles of biomedical research should be responsive to the context of poverty and social inequities since these structural factors can lead to increased vulnerability and exploitation for example the incapacity of poor people to satisfy their basic needs can lead to increased participation in clinical trials without true understanding of risk and benefit at least in part due to financial incentives thus even if these people consent to participation in a trial is that decision truly autonomous it is then clear that research protections cannot be ensured solely through the use of the consent form and the provision of information to the subject a formal provision of consent by the research subject can simply mask the misery that inhibits his or her ability to consent freely similarly what counts as benefits can be tied to different levels of poverty and disease burden in different resourcepoor countries ethical principles and guidelines that oversee biomedical research can be defined in terms of public good rather than merely as an improvement in individual health status because public good and social policy transcend the framework of individualbased ethics 28 in resourcepoor countries deathrates are high and infectious diseases contribute significantly to the burden of diseaseas opposed to richer countries where cardiovascular disease and cancer are the leading causes of mortalitythe difference in exposure health risk mortality and morbidity between poor and rich countries challenges us to develop a new approach to the concept of benefit in biomedical research we need to think of benefits as running to the whole community in which research takes place and not just to single research subjects therefore the availability of and access to modern health services is a substantial issue for evaluating the impact of biomedical research benefits in poor countries since the outcomes of health initiatives are largely determined by some structural arrangements that transcend the benefits of research subjects these arrangements are based upon national and international patterns of control over societys resources current ethical guidelines continue to be inappropriate because they do not address the international context of exploitation within which research is done peoples health status cannot be separated from the capitalist system of resource distribution and exchanges which favors the rich countries or high socioeconomic groups and reinforces the impoverishment of the poor ones the economic exploitation that prevails in the capitalist system shapes the global and local distribution of resources and diseases as well as the health risks and vulnerability of those who live on the margins of the global market the concepts of benefit and justice have been inadequately extended to biomedical research in poor countries because the possibility of exploiting the underprivileged is more complex than an exploitative relationship with vulnerable populations in developed countries where at least the rule of law and the respect due to every citizen have already been institutionalized furthermore the number of research studies conducted in poor countries is increasing because regulatory measures are often less strict this situation may facilitate the exploitation of the poor nonrespect for basic ethical standards and unlimited search for benefit bioethics scholarship that focuses on the sociological model considers local as well as global issues of social inequality because this model is premised on the intimate connection that exists between social inequality and health inequality the distribution of illness is likely to reflect the geography of inequality a social approach to bioethics emphasizes distributive justice and benefits at both the population and individual level three important principles flow from this analysis the first one can be called principle of public benefits it is a contextbased principle which derives from factors that contribute to illhealth and vulnerability to preventable diseases in poor countries it states that risks benefits and equity can no longer be defined in terms of individual health but also in relation to the international national and local contexts 23 such a principle challenges the individualistic understanding of benefits in places where exploitation and inequality are at the center of research consequently a communitybased understanding of benefits calls for a largescale distribution of the benefits of research as an important requirement of justice this principle is relevant for political and socioeconomic critiques of the ethics of carrying on research in poor countries given wellestablished patterns of exploitation and oppression of the underprivileged reliance on the sociological model brings out the fact that the health conditions under study originate in socioeconomic conditions that need to be treated to have an impact on the health status of research participants 28 thus the notion of population or communitybased benefits is related to that of health as a public good which is in turn linked to the globalcapitalistic system that significantly contributes to the health conditions found in poor countries the second principle the principle of social justice is rooted in a broad approach to justice that places poor health at the center of public and research policy and seeks to correct systemic injustices this principle is related to the principle of public benefit since it states that the distribution of benefits should take into account the poverty of local healthcare systems and peoples disempowerment as a function of social structures 23 here the challenge is that the distribution of benefits should address the rootcauses of poor health and not only its symptoms the third principle underscores the need for building local capacity this principle states that building capacity to promote healthcare sustainability will have a lasting effect on peoples health this principle emphasizes the need for building local capacity and improving human capital to reduce the burden of preventable diseases for example research on aids vaccine often uses existing facilities or new ones built by funding agencies to conduct research or administrate the vaccine on trial building capacity may involve researchers and funding agencies improving the training of local medical professionals and reinforcing existing facilities to reduce the burden of disease and if a new medical facility has been built for the research study local communities can still use it even after the research project comes to an end to avoid exploiting the underprivileged and reinforcing an existing system of oppression the distribution of benefits should be determined by the context within which diseases occur the state of the healthcare system and available resources therefore research institutions and their financial sponsors are morally obligated to contribute to the development of a healthcare system and the improvement of human resources that can benefit the whole population carrying on research in impoverished parts of the world where people have been enduring a systemic marginalization would not be ethical if our understanding of benefit will not address the root causes of poor health thus it is no longer enough to avoid not doing harm addressing health challenges that prevail in the research site is consistent with a broader view of justice 28 sociological model bioethics and health policy an autonomycentered ethics places the burden of prevention and access to healthcare on the moral agent in doing so it frames disease within a model that limits political intervention in the health domain strictly to biomedical solutions or behavior change this leads to the perpetuation of the social status quo within which risks for poor health are greater and lends legitimacy to the social forces that increase health risks this failure to promote social justice contrasts with john lynchs understanding of public health intervention lynch believes that elements of the social fabric should shape the conception framework and implementation of public health intervention discussing the influence of socioeconomic status on behavioral and psychosocial risk factors for cardiovascular disease he argues that the public health community should consider the potential for a broad array of social educational and economic policies as effective public health interventions to reduce the unequal distribution of risk factors and the unequal burden of disease 30 similarly bioethicists need to study healthpromoting effects of structural interventions to determine which ones are ethically acceptable and justified such a move requires bioethicists to look at broad issues of social equity and advocate for a shift in public policymaking in a populationbased study examining the associations between socioeconomic status measures reflecting different stages of the lifecourse of 2674 middleaged finnish men health behaviors and psychosocial characteristics in adulthood lynch et al conclude that understanding that adult health behavior and psychosocial health orientations are associated with socioeconomic conditions throughout the lifecourse implies that efforts to reduce socioeconomic inequalities in health must recognize that economic policy is public health policy 31 the sociological model within which lynchs understanding of public health intervention is built challenges us to advocate for a shift in policymaking mindset because health is not a sphere of justice which is separate from other aspects of human life since disease is a social process a policy vision that focuses on the individual and individual risk factors fails to promote social justice and to address structural elements that create conditions favorable to the production of disease hence we need to move from healthcare policy to health policy or rather a healthcare policy that is responsive to facts explaining why people with diseases from communities require medical care health policy should embrace healthcare policies but include considerations regarding welfare work occupational economic development employment and educational policies conclusion sociologists and social epidemiologists challenge bioethicists especially those working in developing countries to be socially and culturally relevant the sociological theory of disease explanation starts with a concrete analysis of the social setting within which illness occurs or research is carried on since societal factors shape patterns of mortality and morbidity principles of biomedical and research ethics need to be framed within the context of the social inequalities that shape vulnerability to illness aligning bioethics to perspectives concerns and information in the fields of public health health policy and medical sociology could vastly improve its global significance thus bioethicists should be challenged to develop a philosophical anthropology that goes beyond radical affirmations of the individuality to acknowledge both the communal and the individual dimension of the human person competing interests the authors declare that they have no competing interests

through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individualbased anthropology mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site emphasizing selfdetermination and freedom of choice however the emphasis on the individual has often led to moral vacuum exaggeration of human agency and a thin liberal conception of justice applied to resourcepoor countries and communities within developed countries autonomybased bioethics fails to address the root causes of diseases and public health crises with which individuals or communities are confronted a sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease freedom medical practice patientphysician relationship risk and benefit of research and treatment research priorities and health policy

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introduction in many industrialised countries unemployed women including fulltime housewives who do not engage in paid work are generally assumed to have poorer health than do employed women this assumption has been confirmed with subjective measurements such as selfrated health assessments in denmark finland norway and sweden 1 spain 2 and the usa 3 and by objective measurements article summary article focus ▪ better general health among workers than among the unemployed is termed as the healthyworker effect and this assumption is applied to women in industrialised countries ▪ many japanese women are unemployed and engage in household chores as fulltime housewives and more than half of working women are in precarious work positions ▪ our hypothesis was that the housewife position is a healthprotecting factor for japanese women and that working women have a greater risk of poor health than do fulltime housewives key messages ▪ no healthyworker effect was found among welleducated japanese women ▪ fulltime japanese housewives were less anxious about and less dissatisfied with their health and had healthier lifestyles than did working women ▪ the social environment that is presumed to support workers should be reconsidered strengths and limitations of this study ▪ all variables were measured by subjective selfreports ▪ limitation on generalisability the observed effect of employment status on women with moderate and lower educational levels is unknown because the study used only highly educated women ▪ strength of generalisability study participants originated from various areas and different socioeconomic backgrounds because the target university was a national institution in a metropolitan city ▪ the number of female university graduates is rapidly increasing in japan thus our findings have considerable relevance to society both now and in the future such as mortality rates in sweden 4 and spain 5 thus most countries have a shared perception that women engaging in paid work are generally healthier than are housewives several recent studies have used this finding to assert that being a housewife is a risk factor for poor health status and is related to poverty low education and lowskilled occupations 6 7 8 at the same time working women are more likely to face the risks of diseases caused by workplace exposure 9 suffer from stress strongly associated with work 10 exhibit unhealthy behaviours during pregnancy 11 12 have higher alcohol consumption 13 and report problems with childbearing 14 than are unemployed women or housewives additionally workers with families face problems caused by work and family roles which exacerbates exhaustion 15 and decreases mental health 16 17 18 despite such workrelated problems several recent studies comparing employment status reported that most unemployed women engaged in household chores in domestic settings and showed poorer mental health status than did contract workers 19 20 behind the common perception that workers are generally healthier than are the unemployed including housewives lies the concept of a healthyworker effect when the relationship between employment and health is discussed at least two types of healthyworker effects are considered the first holds that working people are employed because they have no illness so they are usually healthier than the general population including the unemployed 21 the other is that psychological factors such as improved selfconfidence through engaging in work a feeling of social connection and economic independence make workers healthier 22 based on these assumptions about the healthyworker effect housewives are expected to have poorer health than working women in japan in japan despite an advanced educational background 23 many japanese women do not enter into economic activity and most unemployed women engage in household chores as fulltime housewives although womens participation in the workforce has increased due in part to the equal employment opportunity law revised in june 1985 27 of primeaged women are still categorised as fulltime housewives 24 this high percentage may be attributed partly to the traditional japanese gender role which dictates that women should maintain the household but it is also affected by an inadequate system of job assistance for women such as childcare support and legislation banning gender discrimination in the workplace as a result a huge gap between the proportion of men and that of women participating in economic activity exists in japan 23 although many japanese women choose to work outside the home more than half of working women are in precarious work positions with parttime or outsourced work arrangements 25 in this situation female workers receive very low wages and no social insurance system supported by employers is provided these workers receive only half the hourly wage of fulltime workers for the same work and the difference in conditions between these and regular workers is the largest among organisation for economic cooperation and development countries 26 given such unstable and less rewarding employment opportunities work may be a burden for women rather than a healthpromoting factor moreover a comparative study investigating workers in japan theuk and finland showed that female japanese workers experienced significant conflict between the demands of home and work which induced a poorer mental health status compared with that of male workers 27 therefore we have doubts that the healthyworker effect occurs among japanese women the hypothesis of our study was that the housewife position would be a healthprotecting factor for japanese women and that working women would have a greater risk for poor health than would fulltime housewives methods study population study participants were recruited from the alumnae of a national university located in tokyo to produce a sample with a uniform educational level and relatively common family background in february 2007 we sent reply postagepaid postcards to all 9864 female alumnae who graduated from the university between 1983 and 2006 to ask them to participate and received agreement cards from 1630 by the end of march we then mailed selfadministered questionnaires in april and received 1515 responses by the end of may of these respondents 163 alumnae who graduated before june 1985 were excluded based on the consideration that the equal employment opportunity law was amended at that time prior to survey distribution the institutional review board of teikyo university school of medicine approved the study job status and family demands to assess the effects of both work and family conditions on health status we divided participants into three groups according to family demands and job status housewives working women with family demands and working women without family demands 13 11 12 data from only 1344 participants were used for analysis because eight participants provided an ambiguous description of their family or job status housewives were defined as those who did not engage in paid work and lived with family members who needed care including children husbands and elderly parents working women with family demands were defined as those who engaged in paid work and had family members as described above working women without family demands were those engaged in paid work and had no family member who needed care those who did not engage in paid work and had no family demands such as students or single unemployed women living alone were excluded from the analysis because of the study purpose and the relatively small number of such individuals in addition to job status and family demands participants were also asked about their age place of residence subjective socioeconomic status satisfaction with present employmentunemployment status and the length of time at their present employment unemployment status working women were asked to report average working hours per month employment contract based on the labour survey in japan 25 and shiftwork status health status and behaviour selfrated health lifestyle and preventive behaviour because study participants were expected to be generally healthy and their cooperation with this study was solicited via mail we used subjective health indicators in the questionnaire among women aged 2044 in japan suicide and malignant neoplasm account for almost 60 of the causes of death 28 for this reason we used health outcomes to assess health status preceding suicide and lifestylerelated diseases selfrated health lifestyle and preventive behaviour and knowledge anxiety regarding health was addressed to screen for symptoms of depression which precede most suicides 29 based on previous studies 30 satisfaction in terms of health was explored because the level of health satisfaction was expected to predict the level of health status associated with lifestyle and sociodemographic characteristics respondents were asked to report what they ate for breakfast and how frequently they ate it each week and this information was summarised as a binary variable consumption of a staple food and main dish every morning versus no such consumption sleep conditions were explored based on previous studies 30 31 healthrelated behaviours including utilisation and knowledge of health services were also assessed by asking respondents whether and where they had received a health checkup within the past year and whether they had sought medical consultation within the past year both kinds of utilisation of health services involved preventive behaviours but they differed in terms of phase and cost the former was usually provided in the absence of any objective or subjective symptoms and almost all costs were covered by employers or local government the latter was usually initiated in response to symptoms or suspicion of disease and patients were responsible for at least 30 of consultation fee the following questions were asked regarding knowledge of the healthcare system did you know that employers have to offer workers the opportunity to receive a health checkup at the workplace at least once per year and did you know that the local government has to offer residents over 40 years old the opportunity to receive a health checkup in their community at least once per year statistical analysis the first step in the statistical analysis was to obtain frequency counts or median and 25th75th percentiles of all variables of interest for the three groups according to employment and family status second a χ 2 test was used to compare the housewife group with the other two groups in terms of categorical variables and a wilcoxon ranksum test was used to compare the groups with respect to continuous variables because sleep problems were expected to be associated with irregular lifestyle patterns such as those involved in shift work and parenting of small children sleeprelated parameters were analysed with and without these risk factors finally multiple logistic regression analyses were conducted to estimate the ors and 95 cis for health measurements in association with employment and family status after adjusting for confounding effects for the main explanatory variables housewife status was used as the reference for working women with and without family demands as important confounding variables age marital status subjective economic condition and satisfaction with present employment status were used and confirmed by goodnessoffit in the final model using the likelihoodratio test because married status was a tradeoff of the status of having paid work between housewives and working women without family demands logistic regression analyses were conducted with adjustment for confounding variables other than marital status data analyses were conducted using stata v91 32 all tests were two sided and bonferronis adjustment was applied to the significance level in the case of multiple comparisons a p value 005 was considered significant for the ors results basic characteristics of housewives and workers the basic characteristics of the three groups are shown in table 1 most housewives were married and lived with a partner andor children their median age was 37 years and 23 lived in the metropolitan area almost half considered their economic condition to be upper or uppermiddle class and 62 were satisfied with their present status the age distribution of working women with family demands was similar to that of housewives but their marriage rate was significantly lower than that of housewives most working women were employed as permanent workers and their subjective economic condition and length of tenure at their current job were similar to those of housewives however more working women than housewives were satisfied with their present job status in other words the proportion of housewives satisfied with their fulltime housewife status was less than the proportion of working women satisfied with their employment status the demographic characteristics of working women without family demands were very different from those of housewives most working women were young not married and living alone or with someone other than a partner or child although most were employed as permanent workers a significantly lower proportion of working women than of housewives described their economic status as upper or uppermiddle class however working women were significantly more satisfied with their present job status than were housewives because shift work andor preschoolaged children were thought to be risk factors for sleeprelated problems the three groups were compared in terms of the proportions of participants with those risk factors the housewives group contained the highest proportion of those with these risk factors this was followed by working women with family demands and working women without family demands those proportions reflect statistically significantly differences among groups health status and behaviour anxiety about health was greater among working women without family demands than among housewives greater percentages of working women with and without family demands than of housewives ate insufficient breakfasts the smoking rate was higher in working women without family demands than in housewives sleep duration was shorter in both groups of working women and dissatisfaction with sleep was more frequently reported by working women without family demands than by housewives after excluding those living with preschoolaged children and those working shifts more working women with and without family demands than housewives had received a health checkup in the past year housewives tended to receive a health checkup at the facility designated by the health service of their partners employer followed in descending order of frequency by a community service or at their own expense however the frequency of medical consultation in the past year and knowledge of the healthcare system in the community was lower in working women without family demands than in housewives table 3 shows the risks for poor health status and behaviours in working women adjusted for confounding variables anxiety about health was more prevalent in working women without family demands whereas anxiety about general and physical health was more prevalent in working women with family demands furthermore working women without family demands showed a significantly higher risk of being dissatisfied with their health status an insufficient breakfast and shortage of sleep were significantly more frequent in both sets of working women than in housewives shortage of sleep remained significant after exclusion of those living with preschoolaged children sleep dissatisfaction was also significantly more frequent among working women without family demands and those working shifts and difficulty falling asleep was significantly more common in both sets of working women significantly more working women with and without family demands than housewives had received a health checkup in the past year although knowledge about the healthcare system at the workplace was not significantly different among groups significantly more working women without family demands than housewives were uninformed regarding communitybased healthcare discussion when we compared the health status and healthrelated behaviours of the working women and housewives in the study population housewives had a lower risk of anxiety about health health dissatisfaction a pattern of eating an insufficient breakfast sleep problems and being uninformed about the healthcare system the proportion of working women receiving health checkups was significantly higher than that of housewives however this result must be interpreted carefully workplace health checkups are mandatory in japan under the occupational safety and health law and are readily available because they are often provided during working hours thus a higher frequency of working women utilising the opportunity to receive health checkups was expected additionally although anxious housewives might feel a health checkup to be less necessary than do working women therefore the lower frequency of obtaining a health checkup may not necessarily mean poorer health behaviour anxiety about health was an important subjective symptom among the workingage population because this cohort was exposed to many sources of psychological distress 29 as previous studies have indicated questions about anxiety related to health measure not only health itself but also expectations 33 anxiety about health among working women may derive from their jobs in that they may be unsure about whether they can survive in a work situation a factor that was not a problem for housewives according to a previous longitudinal study the health status of female workers in japan with both regular and fixedterm employment deteriorated after 2004 an a posteriori hypothesis suggested that the increase in precarious nonregular work may have been the main cause of the deterioration in workers health 34 the working conditions of nonregular workers are known to be very poor compared with those of regular workers in terms of salary and welfare systems 26 and opportunities to be a fulltime regular worker are very limited indeed it is often the case that only new graduates became regular workers 35 the system governing the labour market and working conditions may contribute to workers demands to maintain and improve their health we found a significant difference between housewives and working women without family demands in terms of demographic characteristics especially among younger members of the latter group our data indicated that many younger workers did not marry and devoted themselves to regular paid work in the context of the aforementioned labour market and working conditions many japanese women face a choice between a career and marriage this situation may support the aforementioned assumption that workers feel unsure about whether they can survive in the work environment despite the indication that housewives were significantly less satisfied with their present work status than were working women they did not participate in the labour market when asked in the survey why they chose their present status 15 of housewives answered that they retired from work because of their own health problems we conducted an additional analysis excluding those housewives who had retired for health reasons and found that the risk for poor health was higher among working women this result indicates that housewives who had retired for health reasons were in poorer health than were housewives in general although housewives had better health during the survey period than did working women they may have had poorer health in the past when they were working consequently in japan employment may not contribute to improving the health of working women and may as a result render healthy women reluctant to reenter the work force in previous studies in which working women were found to have better health than unemployed housewives researchers described several limitations of their conclusions although healthy female workers have been identified poor health status has also been reported among the younger generation suffering from the burden of the multiple roles of housewife mother and employee 36 our finding that working women with family demands were in poorer health could be explained by these multiple roles although this finding cannot explain why working women without family demands were also in poorer health the difficult working conditions in japan may explain the poorer health of the younger generation furthermore the lack of a protective effect of having children in the home could explain the health discrepancy marriage and parenthood mediate poor mental health among the unemployed 19 and this effect could be associated with our finding of better health in housewives the excess mortality among single working mothers has been associated with the absence of support from a marital partner 22 more than half of japanese working women are in precarious work positions 25 and such working conditions are not especially positive from a financial perspective 26 moreover male japanese workers with family demands tend not to devote time to their domestic situations indeed male workers work longer hours than do female workers and more than half of men participate in leisure activities and regular drinking sessions more frequently than do women 18 in addition to the lack of childcare we think that japanese working women similar to single mothers may suffer from the burdens associated with holding multiple roles related to work and home thus it is not surprising that we found no healthyworker effect among working women although the job assistance available to working women is inadequate several systems support housewives in japan for example japan has had a universal public pension and health insurance system since 1961 and all citizens must participate in these systems japans pension system provides fulltime housewives with various privileges under certain conditions 37 if a citizens spouse is a salaried worker and the citizens annual income is less than 1 300 000 yen the citizen qualifies for a national pension without paying premiums the health insurance system is based on the same principle and salaried workers married to lowincome citizens reap some benefits in terms of tax exemptions in the context of the sex gap characterising earning 37 and participation in economic activities 23 this spousal support system is utilised primarily by women additionally housewives who are divorced or widowed are granted privileges in their tax and social welfare allowances indeed the conditions under which a widow can claim exemption differ by sex until 2009 allowances for dependent children were provided only to women in japan these aspects of the social environment may encourage healthy women to remain in the home and improve their health as a preliminary study we analysed data from a nationally representative survey the 2007 comprehensive survey of living conditions of the people on health welfare 38 to assess the effect of employment status on the selfrated health of women in the cohort aged from 22 to 44 years subjects were divided into three groups according to job status and marital status married subjects engaging in housework married subjects engaging in paid work and unmarried subjects engaging in paid work we conducted similar multiple logistic regression analyses to estimate the risk for poor selfrated health when married women engaging in housework were used as the reference group the adjusted or of poor selfrated health among married working women was 100 and that among unmarried working women was 096 we found no evidence that working women had a significantly better health status than did housewives even when income levels were subjected to greater control to test the effect of socioeconomic status which was used to approximate educational background although the definitions of the groups used in the preliminary study were not identical to those used in the present research our study is consistent with these national data in terms of the health of working women in japan this study has several limitations first all variables were measured by selfreporting objective measures of health status such as biochemical examinations and physiochemical studies would be more appropriate for inclusion in evidencebased assessments of health status it may be feasible to use objective measures to study individuals who belong to a particular healthrelated group such as hospital patients disease or accident survivors and students in a maternity or parenting class by visiting the appropriate venue according to other questionnairebased research that relied on mailed surveys or interviews the observed result should be interpreted as in the range of subjective health status second all participants were adult women who had graduated from a university which may have affected the generalisability of the results because such people often come from higherincome families 23 however the university in question was a national university located in a metropolitan area and the tuition at this institution was lower than that in private universities a report issued by the japan association of national universities indicated that more students with lower income levels attend national than private universities and that national universities can mitigate regional economic disparities between metropolitan and rural areas 39 metropolitan areas tend to attract more than the national average of individuals aged approximately 20 years probably due the educational and employment opportunities available in such places 40 therefore students are expected to come to these areas from a variety of locations around the country thus it is reasonable to assume that participants were drawn from a variety of socioeconomic backgrounds additionally according to a 2007 national survey 24 the number of female university graduates has increased in recent decades from 138 among women now in their early 40s to 269 among those now in their late 20s based on these findings and the study limitations our results can be generalised as representative of welleducated women a group whose numbers are expected to increase in the future we recruited study participants by asking for voluntary participation and 165 of candidate subjects showed a willingness to participate moreover the final response rate was 154 we propose two reasons for such a low response rate first it is possible that some potential participants lacked confidence this survey which was conducted with the cooperation of the alumnae association was the first experience available to this group via this channel indeed the alumnae association had never released contact information for the purpose of a particular study owing to the increased emphasis in japan on the protection of personal information many people have become very sensitive about the use of their private address even for a purpose related to public welfare this has been particularly so since the personal information protection law went into effect in april 2005 which was just before this survey was conducted many potential respondents may have reacted with suspicion to our mailed solicitation of participation in fact the alumnae association received a number of inquiries to confirm that this survey was endorsed by the association this would indicate that many potential participants were sceptical and did not take action the complexity of the study design may have been another reason for the low response rate the survey was implemented in two phases recruitment and participation the complexity of the procedure may have operated synergistically with the aforementioned lack of confidence in that potential respondents were unable to obtain more detailed information about our study including the actual questionnaire until they received the second mailing moreover transfer students were unable to participate owing to the twophase procedure because the school and fiscal years in japan begin in april the effect of not updating contact information on the low response rate remains unknown but can be estimated as very small because the alumnae association frequently uses this contact information to send alumnae bulletins at regular intervals thus from the perspective of selection bias study participants may have held positive attitudes towards public health and related research and maintained relatively stable lifestyles the effect of the former tendency is ambiguous but the latter tendency may have improved the accuracy of our findings given that life transition was a confounding factor we recruited study participants by providing limited information about the study purpose and used several key words employment status and health in our recruitment efforts this approach may have selectively included those who were interested in employment status andor health study participants might be more health conscious than those who did not participate and their health behaviours might therefore be better than those of women of the same age in the general population additionally study participants may have been more worried about their health status as it relates to their job than were those who did not participate as a result the study participants may have had poorer health status than the general female population of the same age however such selfselection bias could work in both directions and it would not be evident which effect was stronger classification errors were unlikely because we divided the participants into housewives and two categories of working women based on objective conditions such as asking about employment status marital status and living with family members although our study design was not longitudinal or interventional we were able to obtain a sufficient sample size with relatively few missing data conclusions this study found no healthyworker effect among japanese women japanese housewives at least those who are well educated appear to have sufficient knowledge to maintain their health to be less anxious about health and to have healthier lifestyles than working women competing interests none ethics approval institutional review board of teikyo university school of medicine provenance and peer review not commissioned externally peer reviewed data sharing statement interested parties can contact the corresponding author

objectives despite being highly educated in comparison with women in other member countries of the organisation for economic cooperation and development japanese women are expected to assume traditional gender roles and many dedicate themselves to fulltime housewifery women working outside the home do so under poor conditions and their health may not be better than that of housewives this study compared the selfrated health status and health behaviours of housewives and working women in japan

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if existing social relationships are unable to meet the individuals social needs people experience loneliness from the perspective of the currently most prominent theoretical approach loneliness is an evolutionarily ingrained warning signal similar to hunger or pain moderate experiences of loneliness indicate missing social connections and serve as incentives to seek closeness with other people thus some experiences of loneliness are common occurrences in all age groups and are not harmful per se in contrast severe or prolonged episodes of loneliness act as chronic stressors that can damage wellbeing and health experiences of severe loneliness have been associated with low levels of subjective wellbeing serious mental and physical health problems and allcause mortality in view of these findings the prevention of loneliness has become a major topic in public and political discourse around the globe in the ongoing debate it is commonly assumed that older adults have a particularly high risk of becoming lonely this belief is probably fueled by the fact that more objective indicators of social integration such as network sizes and frequencies of social contact tend to decline with advancing age the empirical evidence regarding this popular assumption is however rather mixed although some studies demonstrated an increase in loneliness scores in late adulthood others only found stability moreover a recent metaanalysis concluded that there is essentially no association between loneliness and age across adulthood the divergence between the developmental trajectories of more objective indicators of social integration and the development of loneliness across middle and late adulthood could be caused by differential change some groups of older adults may experience less loneliness with age for example because of increases in the quality of their relationships others may suffer an increase in loneliness for example if they are unable to compensate for losses in their closest network on average these differential changes in different groups may cancel each other out at the mean level despite a higher percentage of adults experiencing severe loneliness thus we will focus exclusively on the risk of experiencing severe loneliness in this study a second explanation for the divergent age trajectories of objective measures of social integration and loneliness may be that associations between different facets of objective social integration and loneliness can change across the life span for example although having a romantic partner is probably the most important protective factor against loneliness older adults are on average more satisfied with living as a single than younger adults and tend to be less prone to experience loneliness as a consequence of living without a partner in contrast losses in the number of social activities seem to be unrelated to loneliness in middle adulthood but may increase the risk of becoming lonely in late adulthood again differential changes in the potential impact of different risk factors for lonelinesshere losses in different facets of social integrationmay cancel each other out across the adult life span and may lead to stability at the mean level here we will focus on one of the most important but at the same time probably most overlooked risk factor in loneliness researchnamely earlier experiences of loneliness why are earlier experiences of loneliness strong risk factors for future loneliness experiences of loneliness have a high risk of becoming chronic because long episodes of being lonely may impair the individuals ability to form and maintain social bonds severe loneliness can trigger feelings of insecurity and threat in those affected thus lonely people may perceive their social environment increasingly as hostile as a consequence the individuals motivation to interact with other people further decreases and the lonely adult withdraws from the community of their own accord a vicious cycle develops in line with this prediction longitudinal studies have shown that experiences of loneliness may lead to decreased social activity among older adults across days and across years here we predict that the impact of earlier experiences of loneliness increases with advancing age why are experiences of loneliness particularly harmful for older adults the differential investment of resources model centers around the assumption that forming and maintaining any social tie is not free of charge but requires the investment of time and energy specifically the investment process is conceptualized as a dynamic interaction between individual characteristics and the contextual opportunity structure at the individual level capacitiessuch as the individuals healthinfluence the amount of time and energy available motivationssuch as the individuals perception of their own agingdetermine how much time and energy are invested in specific ties and skills affect the efficiency of the investment the contextual opportunity structure is determined by those people in the individuals environment that are accessible and in principle open to bonding fighting loneliness requires a substantial investment in social relationships becoming less lonely most likely involves new ties being formed or deepening the emotional closeness of existing ties in line with this view one of the rare studies that investigated factors predictive for the transition out of loneliness found that changing from a lonely to a notlonely state was associated with high levels of socializing however forming and deepening of ties are social processes that are particularly resourceintensive older adults are in this regard probably at a specific disadvantage first their capacities needed for investment in social ties tend to be more limited the increasing likelihood of health limitations and illnesses with age may for example limit their abilities for social engagement feeling ill and managing chronic illnesses may reduce the amount of time and energy that can be invested in social ties thus with increasing age lower subjective health as well as a higher number of chronic illnesses may become ever greater burdens for overcoming loneliness second the social motivations of older adults may not be particularly suited to foster investments into new or weaker ties potentially important in this regard are individual views on aging which are known to predict the development of health and wellbeing in late adulthood a positive view on aging in old age has been associated with a greater likelihood of making new friends a higher probability of engaging in social activities and a more positive disposition toward volunteering as well as providing informal help in contrast negative views on agingsuch as perceiving old age as a time with few opportunities for new developments and viewing old age as inevitably linked to social lossmay act as selffulfilling prophesies that impair the motivation to invest in social ties moreover the individuals view on their own aging process tends to become increasingly negative with age consequently negative views on aging may become ever greater barriers to reintegration with advancing age finally the contextual opportunity structure may also decrease with age because older adults may hold fewer social roles than middleaged adults that provide contact to other people however the availability of social contacts in the environment of older persons is difficult to survey because no standard measures have been developed here we will use two proxy measuresnamely partner status and social activitiesthat may capture vital aspects of the opportunity structure for example although a partnership is one of the most important factors for avoiding loneliness it may render overcoming loneliness more difficult older people with partners tend to engage less with friends and neighbors and have on average less bridging potential in their social networks than older adults without a partner thus it can be assumed that people who became lonely despite being in a partnership have more difficulties when they try to reach out to new contacts therefore they havea harder time overcoming loneliness in comparison to adults without a partner in contrast people who have a high level of social activities should have a comparatively large number of potential contacts that could be intensified in times of need high levels of social activities should therefore be positively related to overcoming loneliness however the level of social activities decreases with age and thus losses in activities may create barriers to overcoming loneliness with advancing age the current study in the current study we differentiate between the risk of becoming lonely and the risk of remaining lonely and investigate the respective age gradients of these risks across middle age and late adulthood considering the specific old age disadvantages mentioned earlier we hypothesize specifically the association of earlier experiences of loneliness with later episodes of being lonely is higher in late adulthood than in middle adulthood in addition we will explore whether agerelated changes in individual characteristics and contextual conditions may explain why older adults face more difficulties in overcoming loneliness than middleaged adults we will explore whether accounting for age differences in capacities motivations and opportunities for social interaction may weaken the link between earlier and later episodes of loneliness method sample the data used in the analysis were taken from the german ageing survey a populationbased survey of adults between 40 and 85 years of age living in private households in germany the survey was first conducted in 1996 additional waves followed in 2002 2008 2011 2014 and 2017 in 2002 2008 and 2014 new representative samples were added to the panel the current study encompassed data from all these waves participants needed to provide at least one measurement of loneliness to be included in the sample age gradients were modeled from 40 to 90 years of age beyond the age of 90 data points were too sparse to provide reliable estimates with these restrictions the data consisted of 25963 data points drawn from 15408 participants the sample was on average 6135 years of age at the first measurement occasion about 49 of the participants were female 34 were highly educated and 547 obtained a middle level of education according to international classification standards attritions analyses revealed that participants providing longitudinal data were on average younger healthier had more positive views of their own aging were socially more active and more likely to have a partner sample attrition effect sizes however never exceeded a medium effect size of cohens d 05 full information maximum likelihood estimation was used to address selective attrition and other sources of missing data as long as variables in the model are predictive of dropout and nonresponse which is the case in our study fiml can successfully compensate for biases in parameter estimates measures to ease the convergence in the complex lagged logistic models used in the analysis continuous variables were first transformed to the tmetric all predictor variables were centered on sample means loneliness loneliness was assessed with a modified version of the sixitem de jong gierveld loneliness scale the scale consisted of six statements indicating an individuals subjective view about their social integration participants reported on a scale from 1 to 4 how much a statement applied to their social lives whenever necessary agreement scores for single items were recoded so that a higher score indicated a higher level of loneliness a mean score of 25 indicated that the participant was on average in agreement across all six items this cutoff score was used to create a dummy variable such a categorization identifies very severe experiences of loneliness and categorizes a relatively low percentage of adults as lonely covariates covariates included gender and place of origin because men and participants from former east germany were oversampled in the deas education was included because people with lower education tend to show worse health and higher rates of loneliness than adults with higher education participants reported their highest degree of school and further education with reference to the german education scheme an individuals education was then classified into three categories according to international standard classification of education in addition dummies for assessment in 1996 2002 and 2014 were included in order to control for potential cohort effects age age was centered around 61 years and measured in decades linear quadratic and cubic age variables were included in the analysis capacities capacities were indexed by selfrated health and number of illnesses selfrated health was measured with the question how would you rate your present state of health answers were indicated on a scale from 1 to 5 a number of illnesses was assessed by summing up positive answers about the existence of 11 typical health problems motivations motivations were assessed with two views on agingviewing aging as personal growth and viewing aging as being associated with social losses each facet was measured with four items the participants rated their agreement with the four respective items of each facet on a scale ranging from 1 to 4 all ratings were averaged across the four items higher values implied a more positive view on aging with respect to aging as growth and a more negative view on aging with regard to aging as a social loss opportunity structure we used the number of social activities and partnership status as proxy indicators for the opportunity structure partner status was included in the analysis as a dummy variable the variable social activities was computed as a sum score of nine items asking for engagement in typical activities in the last year activities were classified as social activities if participants indicated in a subsequent question that they had performed this activity together with others analysis the analysis was conducted with mplus 8 the study used a timeseries lagged logistic regression design to examine the associations between earlier states of loneliness on the later risk of being lonely the time span of three years between the earlier and later data points was chosen because it equaled the minimal time span between subsequent assessment waves to account for time spans in the data that were longer than three years a control variable time span was included in the analysis that was centered around three years the clustering of multiple observations being nested within persons was addressed by using the cluster command in mplus the dependent variable was loneliness at t 1 at first we controlled for the stable demographic factors and included the time span variable in a second step linear quadratic and cubic trends for age at t0 were added to estimate the age gradient of the risk of being lonely in three years only significant trends were included in the following steps then being lonely at t0 was added to the model followed by including interactions of loneliness at t0 with the significant age trends as predictors of loneliness at t 1 finally indicators for capacities motivations and the proxies for the opportunity structure at t0 were subsequently added significance tests were conducted using χ 2 difference tests as a robustness check we also explored whether the effects of the covariates indicating capacities motivations and opportunity structure were moderated by age thus we added six agebycovariate interactions as predictors into the final model the significance of these age interactions was verified with wald tests results statistical testing the linear age trend was only marginally significant the quadratic age trend was significant the cubic trend failed to reach significance adding being lonely at t0 as a predictor increased the model fit significantly the interaction between being lonely at t0 and the linear age trend was also significant the interaction with the quadratic age trend was not significant adding selfrated health and number of illnesses increased the model fit significantly adding aging as growth and aging as social loss was also associated with a significant increase in model fit including social activities and partner status further increased the model fit significantly in table 1 all parameter estimates of the final model are shown in the table odds ratios indicate effect sizes moreover wald tests showed that in the final model only selfrated health aging as social loss and social activities demonstrated significant associations with loneliness at t 1 furthermore the interaction between the linear age trend and being lonely at t0 was no longer significant in order to test for additional age moderations we included six agebycovariate interaction terms into the model and ran separate tests for each no significant age interaction was detected all p values were greater than 10 illustration of results the results of the analysis are difficult to interpret without visualization to illustrate the findings we calculated the risk of being lonely in three years in terms of percentages across the whole age range from 40 to 90 years of age figure 1 shows the age gradients of the risk of becoming lonely in three years for people who were not lonely at t0 and the risk of remaining lonely in three years for adults who were lonely at t0 as can be seen age differences were minimal with respect to becoming lonely in fact based on the estimates derived from our statistical model 40yearold people and 90yearold adults had basically the same risk of becoming lonely in contrast age differences were pronounced with respect to the risk of remaining lonely even at the age of 40 people who were lonely had a risk of about 50 of remaining lonely in three years this risk decreased slightly during middle adulthood people in their 60s demonstrated the lowest risk in the sample however at about the age of 75 the risk of remaining lonely increased rather dramatically older adults at the age of 90 had a risk of about 70 to remain lonely in three years when they were lonely at t0 thus our analysis provided supportive evidence for our hypothesis the association of earlier experiences of loneliness with later episodes of being lonely was higher in late adulthood than in middle adulthood the effects of including explanatory variables indicating age differences in capacities motivations and opportunity structures are shown in figure 2 the solid line represents the age gradient of the risk of remaining lonely across middle age and late adulthood without considering age differences in explanatory variables the dark gray line illustrates the age gradient when age differences in capacities were taken into account the effect was relatively small however if all individuals in the sample had the same health the risk of remaining lonely would have been slightly smaller for people who were 55 years of age or older when individual motivations were taken into account the risks of remaining lonely were much lower across midlife and late adulthood moreover the effect of views on aging on remaining lonely became more pronounced with advancing age finally including variables acting as proxies for the opportunity structure further diminished age differences in the risk of remaining lonely in fact after accounting for age differences in capacities motivations and opportunity structures 40yearold adults and 90yearold people showed a similar risk of remaining lonely discussion our analysis indicates that older adults do not have a higher risk of becoming lonely than middleaged adults the risk of experiencing severe loneliness within three years when people were currently not lonely was approximately 65 across middle age and late adulthood this finding is somewhat surprising given the negative age trends in more objective measures of social integration such as network sizes frequency of contacts or social activities our results suggest that older adults are on average rather successful when adapting to agerelated losses in social networks agerelated shifts in older adults social motivations as predicted by the socioemotional selectivity theorysuch as a stronger focus on close social tiesmay for example help older adults to adapt to their shrinking number of social contacts in addition this selectivity may allow older adults to separate themselves from negative social ties which may increase the positive impact of the remaining social network finally many older adults demonstrate beneficial social skills that may enhance the quality of their existing social relationships the aforementioned adaptations in late adulthood and the comparative advantages of older people in terms of social skills may fall short however if the individual has to fight loneliness based on the dire model we predicted that older adults would face more difficulties with respect to overcoming loneliness than middleaged adults because fighting loneliness may require intensive investments into new or weak social ties in line with our hypothesis lonely people that were approximately 75 years or older had a higher risk of remaining lonely in three years than lonely middleaged adults or younger older adults people of 90 years of age demonstrated an about 14 times higher risk of remaining lonely than 40yearold adults controlling for age differences in health that indicate capacities for social investment was associated with a small reduction in the risk of remaining lonely for people that were older than 50 years of age the effect of health issues on the risk of remaining lonely increased slightly with advancing age this indicates that agerelated decreases in health may increasingly hamper the individuals efforts to invest in social relationships individual differences in views on aging and in particular viewing age as a time of social loss demonstrated a strong association with the risk of remaining lonely across midlife and old age moreover the strength of the association increased after the age of 60 this finding implies that motivational characteristics of the individual play a very important role in the fight against loneliness earlier research has demonstrated that a negative view on aging is associated with lower levels of future social engagement thus older people who view aging as inevitably linked to losses in figure 2 the risk of remaining lonely across middle age and late adulthood after considering age differences in capacities motivations and opportunity structure a no age differences considered b loneliness risk controlled for age differences in health c loneliness risk controlled for age differences in health and views on aging and d loneliness risk controlled for age differences in health views on aging social activities and partner status the social domain may invest less in new or weaker ties to counter negative changes in their network in other words viewing aging as being associated with social losses might act as a selffulfilling prophecy in a similar vein it has been shown that older adults who view aging as being associated with losses in physical health engage in less selfregulatory behavior when adapting to a serious health event finally controlling for social activities which served as an indicator of the social opportunity structure further reduced the risk of remaining lonely in particular for adults older than 60 years this result is in line with earlier analyses also using the deas data demonstrating that losses in social activities were associated with increases in loneliness in late adulthood but not in midlife our finding indicates that providing opportunities to engage with other people may become particularly relevant for fighting loneliness in late adulthood because at this age agerelated reductions in social roles may not be caused by voluntary decisions but rather by a lack of options however social activities only assess one aspect of the social opportunity structure of older adults to gain a more comprehensive picture specific measurement tools need to be developed strength and limitations one strength of the current study is the very large longitudinal data set representative of the german noninstitutionalized population between 40 and 85 years of age a limitation of the analysis is however that we were unable to run multilevel models that included all exploratory variables although the timeseries lagged logistic regression model we used for the analysis accounts for time points nested within participants we were unable to differentiate between betweenperson and withinperson effects however because the development of loneliness across the life span is most likely the result of a complex interplay between withinperson and contextual factors this statistical vagueness may not be that important for a first step in the analysis of chronic loneliness nevertheless future studies should integrate more assessments at the individual level in order to be able to differentiate withinperson and betweenperson processes as well as their crosslevel interactions in addition with a higher number of individual assessments it would also be possible to look at the risk of remaining lonely across different time intervals here we were only able to look at the risk of remaining lonely across three years however as an anonymous reviewer pointed out to us irrespective of age the risk of remaining lonely will be high at shorter time intervals because the conditions influencing loneliness have had less time to change the opposite is probably true if time intervals longer than three years are considered another limitation concerns the generalization potential of the study from a theoretical perspective macrolevel factors play important roles in the development of loneliness and empirical studies have demonstrated age differences in loneliness between countries east european countries for example show higher rates of loneliness among older adults than european countries from the north or the west of europe thus the analyses presented here need to be replicated with data from different countries and cultures a final limitation concerns the high levels of missingness in our data set specifically there have been fewer than two data points per participant on average although attrition biases did not reach a medium effect size and we implemented fiml we cannot completely rule out some influence of selectivity implications in our analysis the risk of becoming severely lonely remained basically unchanged across middle age and late adulthood thus becoming lonely is not an inevitable fate in late adulthood at least up to 90 years of age it is important to disseminate this fact as broadly as possible because many laypeople and politicians believe that loneliness is a particular issue of late adulthood as this belief is often and prominently featured in the public debate it might cite negative consequences for aging individuals stereotype embodiment theory would for example predict that people integrate the belief that aging is intrinsically linked with becoming lonely in their views on their own aging processes as our analysis indicates this negative view of aging might in turn hamper older adults investment in social ties in addition our results imply that although experiences of severe loneliness also occur in middle age interventions against loneliness may nevertheless prioritize older age groups after the age of 75 it is increasingly less likely that older adults leave a state of loneliness on their own accord unfortunately systematic reviews are in agreement that most currently available interventions intended to fight loneliness are not effective specifically masi et al deducted in their metaanalysis that only those interventions are successful that address maladaptive social cognitions our results are in line with this statement and imply that people with more positive views of their social aging may transit easier out of states of loneliness furthermore it has been demonstrated in randomized controlled trials that older adults negative views on aging are modifiable thus targeting negative views on aging may be one route by which effective loneliness interventions for older adults might be designed overall this study provided a differentiated view on age trajectories of the risk of becoming and the risk of remaining lonely across midlife and late adulthood it also highlighted potential reasons why older adults may have particular problems with overcoming loneliness however the data were assessed in a specific cultural context and contained high levels of missingness thus replications of this study are clearly needed data availability the data used in the study were from the public release of the german ageing survey which can be accessed via the research data centre of the german centre of gerontology the mplus code of the analysis is added in supplementary material the study was not preregistered supplementary material supplementary data are available at the journals of gerontology series b psychological sciences and social sciences online conflict of interest none

objectives from a theoretical point of view older adults may not necessarily face a greater risk of becoming lonely than middleaged adults but are more likely at a disadvantage in fighting loneliness therefore in this study we differentiate between the risk of becoming lonely and the risk of remaining lonely methods a large longitudinal data set representative of the german noninstitutionalized population from 40 to 85 years of age n 15408 49 female participants was used in the analysis lagged logistic regression models were estimated to investigate the effect of earlier experiences of severe loneliness on the risk of being lonely after three years across middle age and late adulthood individual differences in health views on aging and social activities were taken into account to explore their role in age differences in the risk of remaining lonelythe analysis revealed marginal age differences in the risk of becoming lonely but a marked age gradient regarding the risk of remaining lonely lonely older adults who were older than 75 years of age were more likely to remain lonely after three years than lonely middleaged adults controlling for individual differences in health views on aging as social loss and social activities accounted for this age difference discussion interventions against loneliness may prioritize older age groups because losses in capacities shifts in motivations and a degraded opportunity structure render it increasingly less likely that older adults leave a state of loneliness on their own accord

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introduction catatonia is a complex psychomotor syndrome that often goes unrecognized and consequently untreated prompt and correct identification of catatonia allows for highly effective treatment and prevention of possible complications benzodiazepines and electroconvulsive therapy are the most widely studied treatment methods however no uniform treatment method has yet been brought forward and no previous attempts to treat catatonia on a patient suffering concomitant major depressive disorder with nmda receptor antagonists have been documented so far objectives to describe the unknown and novel management of catatonia and mdd with intranasal esketamine a nmda receptor antagonist methods a 55yearold woman with a diagnosis of longstanding recurrent major depressive disorder who was admitted to the psychiatric inpatient unit of universityhospital marqués de valdecilla suffering a complex catatonic mutative state framed on a severe mdd different ineffective therapeutic interventions were deployed during the course of her illness after failing to improve under conventional pharmacological treatment and ect and given the complexity of peripheral venous access on this patient we decided to initiate compassionate treatment with intranasal esketamine results intranasal esketamine was effective in the resolution of patients complex catatonic state clinical response from catatonia was observed after 6 intranasal esketamine administrations reaching full catatonia and mdd remission after 12 sessions in absence of significant adverse events conclusions esketamine showed promising effectiveness for the treatment of catatonia in the context of mdd although further research on this topic is needed disclosure of interest none declared epv0719 dimensions of role and identity in young informal workers in the tourism sector introduction work is a sine qua non condition of normal life for most people since it is the main source of income feelings and social integration it is an important factor of socialization as well as an identity provider identity was assumed as a constant construction process in which the person is positioned and recognized and which has an important relationship with the dimensions of the role all this in a context of insertion into the labor market for young people which is usually framed in informality objectives describe the dimensions of the role and identity of the young informal worker in the tourism sector of santa marta methods this was a qualitative study with a phenomenological design the participants were selected for convenience and the sample size was determined by the saturation criterion a total of nine young informal workers participated the semistructured interview and the content analysis technique were used for data analysis results the dimensions of status involvement and assessment allowed us to deduce that the role played by young people was central in the description and construction of their identity as well as the implications and the place occupied by the tourist the family and coworkers in the activity that they carry out develop because they are the ones who validate and motivate people to stay and mobilize in that work context expressing so i tried when the tourist managed to capture my attention i started explaining about the… that these dimensions are high indicates that there is a close relationship between role and identity conclusions if identity is read from the social positions that are recognized by others particularly the findings of this research showed that characters such as family tourists coworkers and friends intervene significantly in the recognition of the roles assumed which makes the young person stay in this activity and market as well as find satisfaction in it through the dimensions of the role it was evidenced that at work it is possible to configure the identity of young people for lucena et al when a person who does part of this type of work and refers to it is talking about himself disclosure of interest none declared epv0720 a rare case of trauma related dissociative identity disorder introduction dissociative identity disorder is a debilitating and controversial psychiatric disorder with a lifetime prevalence estimated around 15 it remains underdiagnosed despite recognition in international classification of mental disorders in fact based on the dsm5 criteria did is characterised by two or more distinct personality states that coincide with fluctuating consciousness and changing access to autobiographical memory the aetiology of did has long been debated with recent neuroimaging evidence supporting the trauma model of this condition objectives the aim of this presentation is to describe the case of a young female diagnosed with did related to childhood trauma methods we also conducted a literature review in order to discuss the aetiology of the disorder the following keywords were searched through the pubmed website dissociative identity disorder trauma aetiology results we report the case of a 20 years old female with no past medical nor psychiatric history however she had a family history of an uncle and an aunt with chronic psychosis her father died when she was 8 thus she lived with her mother and her brother and two sisters she was a brilliant student and started engineering studies she has no particular personality trait she was raised within a strict religious family with little time dedicated to leisure activities importantly since the age of 10 she was exposed to her mothers religious extremist and threatening discourses related to death and graves torture and comprising many cultural beliefs she seeks for psychiatric care complaining of soliloquy that became remarkable by her relatives on psychiatric evaluation she presented daily fluctuating consciousness during at least one hour in which she switches identity toward the daughter of a famous singer this alter was having pleasant activity with her mother and was singing and hanging out most of the time no particular triggers were identified the trouble started by the age of 14 then worsened gradually and became an unvoluntary phenomenon with significant distress she had no depressive nor psychotic nor anxiety or obsessive symptoms her sleep and appetite were not disturbed she met dsm5 diagnostic criteria for did and was referred to a trained psychiatrist for adequate psychotherapy management conclusions we exposed a rare case of a young student complaining of soliloquy since the age of 14 that was diagnosed with did subsequent to a particular childhood trauma which consisted in exposure to threatening religious and cultural beliefs about life after death told by her mother this unique case emphasises the trauma model of did where the nature of the trauma influences the clinical expression of did given the recent neuroimaging evidence did can be framed as a chronic psychiatric disorder based on neurobiological cognitive and interpersonal nonintegration as a response to unbearable stress disclosure of interest none declared epv0721 cognitive impairments in moroccan man with a frontal anaplasic oligodendroglioma case study introduction oligodendroglioma is a rare form of glioma developing in oligodendrocytes which are glial cells oligodendrogliomas are divided into two types benign oligodendrogliomas and anaplastic oligodendrogliomas the malignant form objectives the aim of our study is to detect the cognitive troubles caused by a frontal anaplasic oligodendroglioma in a man admitted to the neurosurgery department at the specialties hospital rabat morocco methods a case study was realized among a man aged of 46 years suffering from frontal right anaplasic oligodendroglioma with no medical and surgical history and who presented since two months headaches and forgetfulness and presented two hours ago a fortuitous epileptic seizure followed by notion of amnesia for 5 min at the admission the patient was conscious the glasgow score was of 15 and did not present a motor deficit cognitively the patient was confused we decided then to make him pass the moca test to evaluate his cognitive state as soon as he was admitted to our service and before the surgical act results after passing the moca test our patient had a score of 430 the results in detail gave 05 in the visuospatialexecutive part 33 in the naming part 06 in the attention part 13 in the language part 02 in the abstraction part 05 in the memory part and 06 in the orientation part the score of 430 is less than 1030 and shows a severe cognitive impairment according to his wife his cognitive state was normal before the epileptic seizure and had a normal life conclusions the frontal anaplastic oligodendroglioma in this patient case deteriorated his cognitive state rapidly 13 days after surgery and excision of this tumor the patients cognitive state improved the moca score became 1230 which is in the area of

dissociative disorders are associated with elevated levels of disability impaired quality of life high economic cost and a significantly increased risk of suicide attempts objectives in this work we present the case of a 21yearold man that was assisted in the emergency room with dissociative symptoms we intend to do a nonsystematic review on the subject of dissociation symptoms the psychiatric disorders in which they are present identified risk factors how to access the psychopathology features and the recommended treatment to best address them methods for a comprehensive approach of this subject we proceeded to a nonsystematic review in pubmed using the following keywords dissociation dissociative identity disorder and dissociative disorders results in this work we present the case of a 21yearold man assisted in the emergency room describing dissociative symptoms that were suggestive of dissociative identity disorder he referred outofbody experiences and a sense that he was not controlling his actions while selfinjuring himself and being aggressive towards his family he described three selfs the normal self the suicidal self and the bad self symptoms of dissociation are present in a variety of mental disorders namely depression anxiety disorders posttraumatic stress disorder borderline personality disorder and eating disorders dissociative disorders appear to be linked to trauma interpersonal stress and strongly associated with a history of chronic child abuse an association with alexithymia depression and suicidality were also found some studies found structural and functional abnormalities particularly a reduction in grey matter volume in limbic system structures a dysregulation of prefrontallimbic circuitry and dysfunction of the hypothalamicpituitaryadrenal axis psychotherapy appears to be the cornerstone of treatment for dissociative disorders namely cognitivebehavior therapy and eyemovement desensitization and reprocessing conclusions symptoms of dissociation are not only present in dissociative disorders but they may be present in almost all mental disorders the evaluation of possible dissociative symptoms should be a part of every psychopathological assessment there is a need for further studies to better understand this diagnostic entity and improve the therapeutic intervention

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necessary to advocate a formal policy that might be accepted by diverse societies further research is necessary to apply the findings and recommendations for cse implementation globally in the contexts of different countries keywords comprehensive sexuality education conflicts qualitative study indonesia background comprehensive sexuality education which was promoted by the united nations education scientific and cultural organization in 2009 aims to help young people make responsible choices develop appropriate sexual behavior and acquire appropriate scientific knowledge and skills based on life cycle and culture 12 cse includes scientific information about human development and reproductive health as well as information about contraception childbirth and sexually transmitted infections including hiv therefore the promotion of cse should involve cooperation with the whole school community because it includes not only sex education but also human rights and gender equity cse can provide enhanced decisionmaking and health literacy skills that are applicable to adolescents throughout the course of their life and may facilitate the acquisition of gender equity and human rights based on the appropriate developmental stage 34 sex education is focused on sexual topics such as the prevention of hiv aids the development of sexual organs and menstrual education cse can prevent risky sexual behavior and reproductive health issues among adolescents through comprehensive education on hivaids and other sexual transmitted infections and the prevention of unwanted pregnancy cse has the advantage of potentially preventing child abuse early pregnancy and sexually transmitted infections and also supports the understanding of gender and the building of good relationships 1 a previous study provided evidence of the potential beneficial effects of cse on attitudes knowledge and behavior regarding sexual and reproductive health among adolescents 5 further previous studies reported that adolescents may acquire wellbeing and human rights by learning cse and knowledge and understanding of human rights could influence the acceptance of diverse backgrounds 46 similarly schoolbased sex education helped to enhance grades and reduce the incidence of school dropout due to early marriage and pregnancy 7 sex education in islamic areas is associated with challenges with respect to the lack of a specific strategy and communitybased educational programs provided by national and regional governments 89 a systematic review focused on muslim womens sexual and reproductive health indicated that religious beliefs tradition and culture contribute to difficulty in applying contraceptive methods and accessing information 10 moreover both religion and culture can be associated with these difficulties in islamic societies where certain social behaviors are prohibited or are considered to be unacceptable such as extramarital sexual relations 8 with regard to muslim adolescents talking about sexual content is still taboo between parents and educators due to religious norms and passive attitudes and they also felt uncomfortable discussing reproductive healthrelated issues 1112 hence sex education is still a sensitive topic in islamic societies and an appropriate program and teaching method should be provided to teach sexual content based on religious beliefs the indonesian government initiated a schoolbased hivaids program in 1997 but the program was not formally incorporated into the official curriculum 13 experts on sexual and reproductive health were invited to deliver schoolbased hivaids education 14 a schoolbased learning program was mandated by the united nations to deliver sex education and the sex education program in indonesia is also mandated under the national policy nonetheless utomo and mcdonald 12 and utomo et al 14 and susanto et al 15 reported that like many other countries indonesia still did not have a national curriculum related to sex education and that formal schoolbased sex education programs were still commonly considered taboo or controversial in contrast some parties have supported and strongly urged the government to include sex education as a part of the school curriculum the indonesian national child protection commission is one of the parties that have recommended government implementation of sex education at schools 16 the kpai proposed the inclusion of sex education in the school curriculum in 1999 but it was reported that in 2017 the government still had not responded to the proposal 16 and at the time of writing this is still the case thus indonesia still has no national program and the implementation of sex education has depended on teachers experience and perceptions based on existing subjects a previous study on sex education in indonesia showed that the prevailing conservative views limited some information about sexual and reproductive health and it was generally assumed that teenagers do not need to learn about srh until they are married 17 in contrast the study found that the provision of srh information among adolescents was enhanced by acquiring knowledge of the religion and that learning to manage sexual attitudes in a healthy and responsible manner possibly protected human rights 17 therefore the study recommended conducting srh education or promotion models accompanied by a religious approach to promoting sex education in indonesia teachers have conflicts in the implementation of cse with regard to teaching sexual topics in the local context especially as the delivery of sexual knowledge and contraceptive methods is often prohibited by religious and traditional cultural norms 18 some teachers are afraid that cse promotes sexual curiosity and behavior among students 19 and that through cse adolescents could exhibit more active sexual behavior hence teachers have conflicts in relation to cultural and religious values national policies and personal perceptions based on their experience as educators when teaching cse de haas and hutterb 1819 indicated that the guidance of sex education is related not only to educational institutions but also to national policy and traditional values in the community previous studies in islamic countries reported multiple challenges in the implementation of sex education due to the religious and cultural background of the society and community 9 10 11 the issues of sexual and reproductive health are related not only to stigma relative to sexual content but also to comprehensive topics such as religious norms or the social environment in previous studies the implementation of cse was related to the local context which was mainly limited to christian areas 1819 islam which accounts for approximately 25 of the worlds population 20 has also been shown to be associated with a negative understanding of sex education practices 21 therefore conducting a similar study to identify teachers conflicts in islamic countries and to find solutions to them is expected to provide important insights for the future global promotion of cse this study conducted in indonesia which has the largest muslim population in asia and is home to a diverse mix of ethnicities and religions will not only consider the islamic background of the country but will also explore how the country is embracing diversity and promoting cse a literature review did not identify any studies that focused on the process of overcoming conflicts among teachers in the implementation of cse therefore this study aimed to clarify how teachers overcome the conflicts that they experience in the implementation of cse in schools and to explore how teachers recognize cse and perceive its implementation in schools theory of conflict in this study we applied the theory of conflict to better understand the process of conflicts among teachers and how these conflicts are overcome for the implementation of cse the meaning of conflict was defined as the arousal of two or more strong motives that cannot be solved together in psychology 22 the theory of conflict was advocated by lewin and approachavoidance conflict refers to a decision or behavior that is simultaneously associated with desirable and undesirable consequences 23 thus according to the theory of conflict we hypothesized that conflicts among teachers would impact both their approach to and avoidance of conflict methods study design this study used a qualitative method which triangulated focus group discussions and indepth interviews tolley et al mentioned in 2016 that researchers conduct qualitative research when they need to search for a phenomenon that is not quantitative 24 further the procedure of triangulation was applied to ensure the validity of the study through multiple qualitative data and gained consensus among researchers 25 hence this qualitative study combined the methods of fgds and idis to explore the conflict experienced by teachers in implementing cse at schools sampling procedure this study targeted ordinary public senior high schools in mataram city indonesia this target was chosen because most students in indonesia are educated in ordinary schools in the education system ordinary schools fall under the jurisdiction of the ministry of education and culture whereas islamic schools fall under the jurisdiction of the ministry of religion these schools run in parallel at each educational stage from elementary school to university 26 approximately 80 of students in indonesia are educated in ordinary schools and the remaining 20 are educated in islamic schools 26 first invitations to participate in this study were sent to all ordinary public senior high schools in mataram city as the initial step in the recruitment process ten of the 11 ordinary public senior high schools agreed to participate in this study before recruiting participants for the data collection we estimated the required number of participants to be five teachers and one school principal from each school from the list of potential teacher participants provided by the schools that received an invitation to participate the research team contacted the teachers and informed consent was obtained from each teacher who agreed to participate second we targeted both the school principals and teachers at each school five teachers who are in charge of relevant cse subjects were included in fgds and we selected teacher participants who were in charge of subjects relevant to cse based on the inclusion criteria the teachers subjects included physical education religious education biology civic education and guidance and counseling the participants were selected regardless of age because we could not obtain information on the teachers age moreover the research team decided to limit the number of participants to only five in each fgd session to ensure optimum discussion within the allocated time also the idis were conducted with school principals participants were selected based on their work experience and their availability to participate in online data collection participant characteristics in total 49 teachers from 10 ordinary public senior high schools in mataram city participated in the fgds their mean age was 413 years most participants reported that they were muslim two participants reported that they were hindu the mean teaching experience was 14 years for the idis 10 school principals participated in this study their mean age was 491 years the mean teaching experience was 216 years all principals were muslim online data collection data collection for this study was conducted through fgds and idis using an online methodology fgds were conducted to elicit the process of overcoming conflicts through discussions among teachers whereas idis were conducted to reveal detailed managementlevel challenges experienced by school principals ten fgds and 10 idis were conducted with all participating schools between june and september 2021 the fgds were conducted at 10 ordinary public senior high schools in mataram city based on the online protocol and interview guide the average duration of the fgds was 1 h and 53 min we targeted the school principals with the idis because we presumed that we could clarify how teachers overcome the conflicts that they experience in the implementation of cse in schools furthermore we hypothesized that the role of the school principals and how they engage with the conflicts in the implementation of cse at school could be explored thus the idis targeting the school principals were conducted using specific questions to clarify any obstacle or challenge at the management level the mean interview time was 51 min process of transcription and translation the fgds and idis were conducted in bahasa indonesia and the interviews were transcribed by referring to online data processing that was developed through pretesting 27 the research team from the university of mataram was responsible for participant recruitment conducting the data collection and translating the qualitative data from bahasa indonesia into english after every interview recorded audio data of the zoom meeting were transcribed using google docs by the principal investigator translation of the transcripts was conducted by the research team from the university of mataram using both the google docs transcription and the recorded audio data of the zoom meeting these two materials complemented each other in the translation process and ensured the validity of the transcription furthermore the google docs transcript reduced the time needed to transcribe the recording and the recording helped to identify and correct inaccuracies in the transcript data analysis the data from the fgds and idis were analyzed using thematic analysis for qualitative study methods in the data analysis of this study we applied a deductive thematic analysis as proposed by boyatzis in 1998 28 we considered the predicted outcome and created the interview questions by referring to both technical guidance on cse 1 and the previous study relevant to focusing on teachers conflicts in implementing cse 18 de haas and hutterb reported on the outcomes of studies that focused on teachers conflicts and their professional identities in comprehensive schoolbased sexuality education 1819 thus we analyzed the qualitative data deductively and clarified the analyzed data compared with the previous study to evaluate the novelty of the present study after data processing data analysis was conducted by deductive thematic analysis methods the data analysis process was divided into seven steps coding creating subcategories integrating subcategories into the theory of conflict integrating the subcategories into cse concepts creating categories integrating into themes and theoretical development the coding was conducted using the maxqda 2018 analytic pro qualitative analysis software program 29 finally the data analysis and theoretical development were regularly discussed with advisors and acquired a consensus that indicated agreement among coresearchers to reach reliability throughout each procedure trustworthiness of the study regarding the trustworthiness of the study we tried to ensure reliability through online data collection and data analysis and three classified procedures were mainly applied as follows first member checkingrespondent validation at the end of the fgds and idis we provided a summary of the discussion to the participants and asked them to confirm and correct our notes and interpretation member checking supports the credibility of a qualitative study second triangulation two sources of data were used in this study teachers as the implementers and school principals who oversee and manage the teaching processes the conflicts and challenges conveyed by teachers were confirmed by the principals in addition triangulation was also carried out in the data analysis the members of both research teams from the university of the ryukyus and the university of mataram were involved in the data analysis triangulation of data sources and analysts supports the credibility and reliability of the study finally to support the transferability of the findings we already provided detailed information about the context of this study including the sample setting and results so that the audience can evaluate how the findings are relevant to their contexts results according to the theory of conflict lewin introduced three models of conflict approachapproach conflict avoidanceavoidance conflict and avoidanceapproach conflict 23 in this study the conflicts among teachers in implementing cse were adapted to the model of avoidanceapproach conflict because the process of conflicts not only included the negative but also the positive thus we applied the theoretical development to both conflicts such as avoid conflictacceptance process and approach conflicteffort process a total of 155 codes were divided into 73 codes for acceptance process and 82 codes for effort process nonresponse 0 additionally the percentages of the codes through two processes were 471 for acceptance process and 529 for effort process this meant that acceptance process and effort process were approximately equivalent and two processes of conflict were comparable among teachers to integrate the subcategories into the theory of conflict the subcategories were abstracted into this theory based on the two perspectives of acceptance process and effort process moreover the subcategories were divided into causes of the conflicts and overcoming the conflicts through theoretical development therefore we analyzed the created themes through both the processes of acceptance and effort six themes emerged from the fgds and idis related to conflicts experienced by the teacher participants in teaching cse and how these conflicts affected their teaching these six themes were created from 16 categories and 36 subcategories through deductive thematic analysis our analysis was based on two phases that focused on the process of teachers conflicts in implementing cse the acceptance process phase and effort process phase causes of the conflicts were represented by themes 1 to 3 lack of confidence among the teachers students sexual behavior and influence of diverse backgrounds overcoming the conflicts were represented by themes 4 and 5 perception of cse implementation among teachers and cooperation with multiple stakeholders also these themes explored the perceptions of teachers in implementing cse in schools based on their experiences and the subjects they were in charge of furthermore theme recommendations for the national and regional governments showed suggestions and opinions for promoting cse the created themes were developed based on the theory of conflict which has two aspects of acceptance process and effort process as shown in fig 2 it refers to the theory of conflict that was advocated by lewin in 1935 fig 1 flowchart of deductive thematic analysis lack of confidence among teachers teachers had no confidence in the implementation of cse because their knowledge and perception about sex education were still incomplete most teachers had not experienced training in cse under an official curriculum or guideline and teaching sex education was dependent on the teachers approach the teachers perception of sexual education is still biased there are still pros and cons but maybe the problem is because the teachers understanding of sexual education is incomplete we face all sorts of difficulties at school some students are open to this topic but some are quiet it students sexual behavior some of the teachers were afraid of encouraging sexual behavior among students outside of school due to the development of social media which has influenced the understanding of sexual information among students further students come from multiple backgrounds and therefore teachers must consider different religions and family situations when teaching sexual content students are now smarter than their teachers because they are very active on social media and have a wide range of interactions so when we talk about matters related to sexual education the students already understand all about those things students these days have a high degree of curiosity they know more than us even before we tell them its all because of modern technology all students have a cell phone so its not difficult for them to obtain information some teachers reported being afraid that students learn sex education outside of school because it must be accomplished through moral education and norms moreover some teachers mentioned that due to the delay in delivering sex education to high school students their curiosity might encourage sexual behavior and misunderstanding to avoid learning sex education outside of school it seems that students should acquire decisionmaking skills to emphasize the importance of religion norms and morals we hope that the students do not learn sex education outside of the school environment which we are afraid of therefore it should be emphasized that sex education in schools must be accompanied by moral education and norms puberty starts at 13 years of age its safe to say that wellinformed parents could give some input on that but if the parents perceived this kind of talk as a taboo they may be too embarrassed to talk about such issues then it will be too late to deliver such information many teachers noted that the traditional culture still supports early marriage in lombok island because students sexual behavior is related to traditional culture in the sasak community which still promotes early marriage some of the teachers felt it difficult to have a good relationship with students and family due to the multiple backgrounds from the cultural perspective in lombok we have merariq merariq is snatching a bride some will consider this to be something that is easy or normal to do but from a human rights perspective even when womens nature is to give birth they also have the right to feel satisfied thats what we need to teach to our students their rights and boundaries since there are many examples of underage marriage in our society most students understood the consequences almost every child that married young has dropped out of school the teachers mentioned that sex education was needed for adults too because if parents have appropriate knowledge they can help their children in addition a bad relationship between students and parents impacted students attitudes and morals and this underlying factor was associated with disharmonious relationships with parents i usually emphasize the aspect of relationships such as having a harmonious relationship with their family to children because for students who have a lot of problems at school the underlying factors are related to disharmonious family relationships bad relationships within the family at home will also affect the students at school… influence of diverse backgrounds this theme titled influence of diverse background related to how other religious and cultural backgrounds interacted with islam or sasak culture in influencing cse or conflicts in teaching cse it was mentioned that the diverse cultural and religious background in indonesia influenced the implementation of cse some of the teachers taught about zina in religious regulations through a lecture on religious education we need to set the boundaries in interacting with people according to their respective religions i believe that every religion prohibits zina contraceptive devices are one of the birth control methods but in islam its forbidden to use such devices when youre not married although the teachers are afraid of students possibly misunderstanding sexuality some of them emphasized that morals and faith might be contributing to the enhancement of sexual topics that were still taboo and sex education caused conflicts due to religious and cultural norms what we must instill in our students firstly is faith and morality if their morals and faith are good they can avoid things that are not good so the first thing we instill is morals and faith …people have often misunderstood this sexual education this is as far as i understand as a teacher who has been in the midst of students for so many years so the fear arises in society because of their inadequate knowledge of sexuality i think thats the root of the problem sexual content is still regarded as a sensitive topic in the local context making it an obstacle to considering a solution to some sexual issues with the teacher talking about sex education openly caused uncomfortable feelings and this discomfort hindered the teacher from discussing sexualityrelated lessons when talking about sex or human anatomy we face the problem at school because some might feel embarrassed or uncomfortable talking about that topic so blatantly not everybody is used to talking about such a subject in such a vulgar manner perception of cse implementation among teachers theme 4 indicated that cse is implemented through multiple subjects based on the common perception among teachers because almost teachers acknowledged providing cse to students to prevent their risky sexual behavior according to the interviews with teachers sex education is taught in physical education and biology furthermore religious education civic education moral education and guidance and counseling were supported for students to gain an appropriate sexual attitude and life skills …we teach healthy relationships between teenagers the material includes the prevention of early marriage the material in 10th grade physical and health education is mainly about how we maintain social interaction it through physical education approaches such as using sports as a diversion a biology teacher taught students about the use of contraception through a lecture to deliver some options for contraceptive methods another teacher recognized the importance of delivering sexual topics to students which are expected to contribute to their future there is a theory regarding contraception in biology based on my understanding i also explain that there is natural contraception such as the calendar method so i do not encourage or discourage one particular contraceptive i want the students to know that they have options i think it is important to teach them about it so that they will know the options for contraception when they become mothers later religious education included cse content to avoid misunderstanding and trouble among students a religious education teacher noted that cse has the same purpose and concept as islamic study we explain what would happen if we commit adultery including the two categories of adultery the social punishment and the religious punishment the impact on their families and the community we also explain how to avoid promiscuity or adultery for example by participating in positive activities such as extracurricular activities at school and religious activities and also by maintaining a safe relationship with friends content on relationships with family and good attitudes toward religious norms were presented by civic education teachers indonesian society has rights and cultural values which are acknowledged based on the principle of the pancasila there are rights and cultural values in our society we live in a heterogeneous society with many different backgrounds and characters i told them the importance of holding on to pancasila the first principle belief in the mighty god is important because it covers the other four principles when we understand our religion we know that every action is followed by its consequences a guidance and counseling teacher emphasized that support for students is important for their learning process because the support system provided by teachers influenced students concentration and psychological stability a public senior high school organized a religious counseling guidance team to support students who had problems the sole purpose is for students to receive psychological support to stay focused so that their teaching and learning process remains normal… that is why we teach them about free sex or juvenile delinquency its impacts and how to deal with it if there is a problem usually the homeroom teacher gives advice first then gradually the bk teacher and later the religion teacher at this school i form a team called the religious counseling guidance team so this is a collaboration between homeroom teachers bk teachers and religious teachers to provide understanding to students a teacher noted that character building or character education helps students to understand the situations or the environments they can adjust themselves accordingly which allows students to solve problems by themselves when they occur regarding character building we hope that they can understand their environments including the school environment their own home environment and their social environment as students in counseling we collaborate a lot with subjects such as pancasila and civics religion indonesian language as well as other fields social relationships with family and good attitudes toward religious norms must be developed one teacher mentioned that students should follow religious norms in daily life and family interaction is quite essential for young people to have good relationships in the community and society every morning starts with people praying together according to their believe hindus in one class and muslims in another class we use that occasion to approach the students not just about sex education but also about social relationships and so on cooperation with multiple stakeholders a health worker working in primary health care was invited to give socialization lessons on adolescent reproductive health the primary health care doctor explained the human reproductive system and reproductive health and teachers hoped that students would share information with each other we invited from primary health care workers several times for socialization about adolescent reproductive health but not all students attended usually only representatives could attend such as the student council the class president or the leaders of extracurricular activities some teachers explained about school cooperation with nongovernment organizations or agencies that focus on health education particularly in relation to sex education and hivaids plan international is an organization that promotes childrens rights and equality for girls they helped us to give lectures to our students… they also held virtual meetings with the students their lectures are related to comprehensive sexual education the teachers you have interviewed before also slip in materials related to comprehensive sexual education in their classes especially biology and islamic studies there are programs from the government to introduce it at school recommendations for the national and regional governments it was emphasized that piety faith and morals are essential in living life and schools need to work together with parents and families to help students develop their understanding of sexuality issues the traditional community is still promoted early marriage such as the traditional sasak culture of lombok island in lombok the religion and culture are in line the existence of cse is helpful in the community especially regarding merarik kodeq hopefully government policies are positively in line with comprehensive sexual education the concept of introducing cse should be disseminated and socialized more so that it is more easily accepted in society an intervention by the religious leader provides social values and mutual assistance in the community the religious approach was recommended by the schools principal because sex education is related to religious norms we need to involve government officials local youth organizations and religious leaders related to morals and norms they have big roles in educating the general public religious leaders also deliver comprehensive sexualityrelated materials and their related social values such as mutual assistance mutual assistance or helping each other is still practiced by the community in order to achieve harmonious relationships within the community a civic education teacher suggested implementing cse under a policy such as an umbrella act which refers to a set of regulations or legal instruments from the government one school principal mentioned that educational methods should be improved through a curriculum or learning tool …it is important to have an umbrella act for its implementation because if there is no law about it it would be difficult to be implement i think we need to have a sustainable plan so it is also necessary to involve the government in providing socialization of comprehensive sex education as continuous learning a guidance and counseling teacher mentioned the necessity of a cse handbook because there was no trusted information source regarding cse the development of an official guideline may be an informative information source discussion the purpose of this study was to clarify how teachers overcome the conflicts that they experience in the implementation of cse in schools and to explore how teachers recognize cse and perceive its implementation in schools the study revealed mutual recognition among teachers and the acceptance of diverse backgrounds in the implementation of cse at ordinary public senior high schools in mataram city indonesia according to the results these two findings identified that the subcategories synthesized the findings in the theory of conflict based on two perspectives acceptance process and effort process throughout the theoretical development first we identified that boundaries need to be set in interacting with people according to their respective religions through the acceptance process because each religion has diverse norms and practices to follow among the public in the region second this study identified the mutual recognition among the teachers that they implemented cse based on their respective fields roles and expertise because most teachers as educators acknowledged that early marriage and unwanted pregnancy should be avoided among students the perception among teachers was that cse could presumably prevent these reproductive health issues and this challenge encouraged their motivation to implement cse furthermore it was acknowledged that multiple subjects were related to the implementation of cse and that teachers cooperated with the school community society and multiple stakeholders therefore the two main findings indicate that teachers adapted cse to follow multiple religions and cultural backgrounds diverse backgrounds students sexual behavior and lack of confidence among teachers were causes of conflict in implementing cse multiple religions and ethnicities coexist in indonesia and the government advocates unity in diversity 30 many of the teachers were afraid to teach sex education because sex is still a taboo topic and religious norms and traditional culture still strongly exist in the community it should be noted that unity in diversity is associated with teachers perceptions in mataram city religious norms are related to both islam and hinduism 31 moreover the traditional sasak culture still promotes early marriage among young people in the community 3233 some of the teachers mentioned that the traditional practice influenced students active sexual behavior and was associated with dropping out of school they made efforts to solve students health issues given their different backgrounds and perceptions from these findings it was indicated that the teachers backgrounds were based on the country context this study showed that moral education is comprehensively provided through several subjects including civic education based on pancasila 34 religious education and guidance and counseling moral education was recommended by the indonesian government to enhance students morals and the protection of their rights and it was advocated based on the longterm development plan for 20052025 35 furthermore religious education could increase awareness of religious beliefs and practices and influence the personal family and community spheres 3637 because religious beliefs are related to both perspectives of sexual and reproductive health and religious norms therefore moral education might enhance students attitudes through the comprehensive curriculum that was integrated into civic education and religious education several health institutions are already collaborating to guide sex education in ordinary public senior high schools such as the health department primary health care workers international ngos and the national family planning coordination board plan international promoted cse under sexual and reproductive health and rights and it might promote the acceptance of cse in society 38 a private health sector intervention relevant to sexual and reproductive health and rights was implemented in europe 39 the cse curriculum and guideline in the netherlands were developed by rutgers international which is an organization in the private sector that implements activities based on the national policy and statements from several agencies 40 in addition cse training was provided to educators by rutgers international based on the created curriculum and guidelines it was previously reported that the private sector provides many sexual and reproductive health activities in lowmiddle income countries 41 the cse policy paper reported by unesco suggested that cooperation between both the health sector and private sector could link school health services 42 further private sectors may cover areas of the education sector lacking the intervention according to the international technical guidance on sexuality education it was developed to support an organization in both education and health for promoting sexuality education programs in and out of school one recommendation would be to involve several parties not only an organization in both education and health but also one that cooperates with private sectors at the national and school community level hence it was suggested that linkage with the private sector should be pursued to promote cse in the community and society this study indicated that promoting cse may require cooperation with the community and society leadership from school principals and the implementation of cse under a formal policy first it would be recommended to involve both the traditional community and parents due to the influence of traditional practices second through the leadership of school principals the acceptance of cse could be promoted by encouraging cooperation among schools the community and society as a previous study indicated that school principals play a critical role in providing school direction and determining the culture based on the context for each school 43 moreover the leadership of school principals could contribute to the realization of healthpromoting schools and help foster cooperation with the school community and stakeholders 44 finally it was indicated that a policy would be needed to formally promote socialization of cse it was considered that cse was implemented by mutual recognition among teachers but to provide more specialized education it would be necessary to advocate a formal policy that might be accepted by diverse societies thus this study showed that the national and regional government would need to advocate a policy relevant to cse as one limitation of this study further research needs to be carried out to apply the findings to other countries although this study was undertaken to explore the global promotion of cse it was strongly related to the country context at the study site while the original indonesian educational system and diverse backgrounds are associated with the main findings of this study the findings may not apply to the context of another country because cse is related to religious norms cultural backgrounds and gender perspectives and adapting all of the findings to another setting would be difficult in addition this study suggested that the difficulties of cse need to be weighted for each challenge or suggestion because it was necessary to clarify the levels of issues related to cse in the process of the data analysis themes were generated at the school community and national and regional government levels but the priority of recommendations was not clear hence it is recommended that further research be conducted in other locations based on the country and local context and it will be necessary to make recommendations according to the priorities of each location conclusion the conflicts experienced by teachers in mataram city indonesia in the implementation of cse were mainly related to religion cultural background and gender inequality despite teachers reporting multiple conflicts they made efforts to overcome these conflicts through mutual recognition and provided comprehensive guidance thus the teachers accepted the diverse backgrounds of their students and provided cse by collaborating with related educational subjects and external institutions to overcome conflicts further research is necessary to apply the findings and recommendations for cse implementation globally in the contexts of different countries abbreviations cse comprehensive sexuality education fgds focus group discussions idis indepth interviews kpai komisi perlindungan anak indonesia srh sexual and reproductive health unesco united nations education scientific and cultural organization author contributions fs and jk conceived the presented idea and designed the study dps cw awr and hk conducted online data collection in the field fs rt and jk conducted data analysis fs drafted the manuscript dps cw awr rt tecjk cdlr hk and jk critically reviewed and edited the manuscript all authors reviewed the manuscript drafts and approved the final version all authors read and approved the final manuscript competing interests the authors declare that 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 comprehensive sexuality education cse which aims to help young people make responsible choices and acquire scientific knowledge and skills has been promoted by unesco teachers experience conflicts in implementing cse when teaching sexual topics in the local context especially as the delivery of sexual knowledge and contraceptive methods is often prohibited by religious and traditional cultural norms it was reported that there were multiple challenges in the implementation of sex education due to the religious and cultural background of societies and communities in islamic countries this study aimed to clarify the process of overcoming the conflicts explore teachers recognition and perception related to the implementation of cse and to suggest recommendations for promoting cse in islamic areas methods this qualitative study combined the methods of focus group discussions fgds and indepth interviews idis to explore the conflict among teachers ten ordinary public senior high schools in mataram city indonesia agreed to participate and in total 59 participants were involved in this study fgds were conducted with teachers n 49 and idis were focused on school principals n 10 in each school the collected interview data were analyzed using a deductive thematic analysis and the findings triangulated for both the fgds and idisoverall the teachers experienced conflicts in relation to religion cultural background and gender inequality in implementing cse the present study revealed the mutual recognition among teachers and acceptance of diverse backgrounds in the implementation of cse at ordinary public senior high schools in mataram city despite teachers reporting multiple conflicts they made efforts to overcome these conflicts through mutual recognition and provided comprehensive guidance the present findings indicated that teachers adapted cse to follow multiple religions and cultural backgroundsthe teachers accepted diverse backgrounds and provided cse by collaborating with related educational subjects and external institutions to overcome conflicts to provide more specialized education it would be

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background the world health organization in cooperation with several other international organizations published a report that called for a reduction in the global maternal mortality rate to less than 70 per 100000 live births by 2030 1 the maternal mortality rate in japan was 33 per 100000 live births in 2019 which is low compared with the rest of the world however the maternal suicide rate was extremely high at 87 per 100000 live births in the 23 wards of tokyo during the 10year period from 2005 to 2014 2 depressive disorder is one of the risk factors of prenatal and postpartum suicidal ideation with a higher prevalence of depression in women who attempted suicide postpartum than during pregnancy 3 meanwhile postpartum depression is a risk factor for suicide 4 and maltreatment of children 5 and thus early detection of postpartum mental health problems and appropriate intervention are essential for both mothers and child health services in addition bonding disorders associated with postpartum depression 6 and maltreatment of children are also major problems therefore countermeasures against postpartum depression are considered an urgent public health issue a previous study reported that the continuum of care for maternal neonatal and child health was associated with a reduction of 500000 maternal deaths 4000000 neonatal deaths and 6000000 child deaths globally each year and suggested that expanding postnatal care might result in further reductions 7 the who recommends a minimum of four postnatal care contacts as well as home visits by health professionals 8 in japan where approximately 98 of births take place in hospitals or clinics and mothers are often discharged about a week after delivery each municipality conducts home visits to families with infants within 4 months of birth through a welfare program called konnichiwa akachan jigyo 9 in this program public health nurses midwives or other health care professionals visit all families with infants in the area interview them regarding their concerns about childrearing and provide information on childrearing support provided by the municipality at the same time they screen for postpartum depression using the japanese version of the edinburgh postpartum depression scale 1011 a study found that continuous support provided by integrated mental health care through a multidisciplinary maternalchild health service in the community improved the mental health of postpartum women and increased their access to more health services 12 their findings suggest the importance of maternalchild health services involving home visits the global coronavirus disease 2019 pandemic has drastically changed peoples lives and affected the maternal and child health care field in japan people were asked to change their lifestyle to prevent the spread of infection by avoiding the three cs practicing physical distancing wearing masks and washing their hands a state of emergency was declared four times from april 2020 through june 2022 by the japanese government which urged citizens to reduce persontoperson contact including refraining from unnecessary outings and travel between prefectures and requested that some business facilities close temporarily or reduce their business hours at childbirth facilities childbirth preparation classes postpartum visits by family the attendance of partners at the birth and the acceptance of pregnant women relocating from other prefectures were prohibited 14 in japan it is customary for pregnant women to return to their parents home to prepare for childbirth this is known as satogaeri bunben 15 and is a traditional form of childbirth support in japan 16 more recently an increasing number of local governments have begun to provide public subsidies to postpartum care facilities as an alternative public service to satogaeri bunben however there was a period when many mothers were unable to give birth in their hometown because of calls to refrain from travel between prefectures and because many postpartum care facilities stopped accepting mothers from other prefectures as reported by a recent study in japan 30 of pregnant women who hoped to return to their hometown for childbirth could not do so because of the covid19 pandemic 17 these women are likely to have experienced more stress than those who were able to return to their hometown for the delivery as scheduled during the covid19 pandemic postpartum mothers might have experienced an increase in anxiety due to the lack of social support in japan the prevalence of postpartum depression among mothers who gave birth and took care of children during the pandemic was 287 18 double the prevalence of reported in a metaanalysis of japanese women published in 2020 19 according to that report this change may have been due to the fact that an increasing number of mothers were unable to go out as much as they would have liked were unable to return to their parents home or ask their parents for help and were unable to meet with friends or interact with others who gave birth around the same time under such circumstances health care professionals visiting the homes of families with infants are likely to experience new and unprecedented difficulties in fact it has been reported that at least 60 of municipal public health nurses who communicate directly with community residents had experienced mental health difficulties 20 however few studies have investigated the difficulties experienced by health care professionals who visited the homes of families with infants during the covid19 pandemic a study conducted in china reported that health care workers employed in hospitals during the covid19 pandemic needed support to prevent exhaustion 21 we believe that providing support that addresses the difficulties and challenges faced by health care professionals is essential to prevent turnover due to exhaustion thereby enabling them to continue to provide support for postpartum mothers to that end we considered it necessary to conduct a preliminary study to identify the challenges faced by health professionals who visit postpartum mothers directly and to examine whether solving these challenges in the future would improve the care and mental health of postpartum mothers in the community accordingly this study conducted focusgroup interviews with health care professionals who make home visits to families with infants with the aim of clarifying the difficulties they have faced during the covid19 pandemic and considering how to provide better support for mothers and infants in the future methods study design this is an exploratory qualitative study using focusgroup interviews the study is reported following the standards for reporting qualitative research framework 22 data collection this qualitative study was conducted by means of focus group interviews as a research question we attempted to identify what difficulties health professionals who visited the homes of postpartum mothers with children up to 4 months of age in city a had experienced during the covid19 pandemic participants were divided into two groups according to their work schedule the first group attended an interview session on november 11 2021 that lasted 81 min and 53 s and the second group attended an interview session on december 16 2021 that lasted 104 min and 49 s a state of emergency had been declared four times since april 2020 in response to the covid19 pandemic with the fourth state of emergency being lifted on september 30 2021 during the group interviews we used an interview guide that included the following questions do you have any difficulties at work what has changed or been difficult for you in providing support for mothers since the start of the covid19 pandemic which cases did you find especially difficult interviews were conducted in a wellventilated room in a municipal facility where privacy could be ensured the interviews were recorded with a digital voice recorder after obtaining the permission of the study participants interviews for each group started with an introduction and then proceeded with questions for participants about their difficulties in providing support to mothers and their children during the pandemic data analysis the interview recordings were transcribed verbatim first the first author read all of the transcripts then coding of the transcripts was performed to generate a preliminary list of codes the transcripts were imported to the analytical software maxqda 2022 and codes were generated to systematically capture interesting aspects of the data across the entire dataset we used a thematic analysis approach because it allows for a flexible and nuanced account of the data 23 codes with similar content were grouped and labeled and then subcategories and categories were generated analysis was performed with the input of multiple researchers in order to ensure validity one author performed the preliminary analysis and another author served as a second independent coder of the data the initial coding was then reviewed and compared the codes were further reviewed and refined through discussion until consensus was reached among all authors to analyze the relationships between categories one author created a preliminary diagram of the codes subcategories and categories after all authors had reviewed and discussed all the codes and categories a refined diagram was completed based on saturated logic ethical considerations this study was approved by the teikyo university medical research ethics committee and all methods were performed in accordance with the declaration of helsinki consent to participate was obtained in writing participants were reminded that they could stop their participation in the interview at any time without giving a reason identifying information was removed from the transcripts to protect participants anonymity results difficulties experienced by healthcare professionals who visited the homes of families with infants to screen for postpartum depression during the covid19 pandemic focus groups interviews were performed the total interview time was 186 min and 42 s and the total word count of the verbatim transcript was 48460 words from these sentences 175 codes were generated using the inductive coding approach following the principles of reflexive thematic analysis 23 furthermore the coauthors decided on 11 subcategories after discussing the subcategories and codes based on saturated logic a qualitative analysis of the interview data was performed which led to the identification of four categories of difficulties experienced by healthcare professionals who visited the homes of families with infants during the covid19 pandemic lack of support for partners difficulty in talking facetoface inability to offer family assistance and anxiety about being a source of infection category 1 lack of support for partners after the start of the covid19 pandemic healthcare professionals noticed that mothers and their partners were spending more time together at home at the same time providers considered it important to assess partners attitudes toward childcare and health status but they found it difficult to talk with the partners without standard assessment tools this category comprised three subcategories due to restrictions on going out during the covid19 pandemic as well as the increase in people working from home partners were spending more time at home however they seemed to struggle with uncertainty about how they should assist mothers and children health care providers had difficulty regarding how to intervene i dont have the necessary tools and im still a little unsure of what her partner thinks and how he perceives the birth of his child although health care providers were able to assess mothers and children during visits by using epds physical measurements and interviews the lack of assessment tools for the partner present made it difficult for them to deal with the situation at the time of the visit the partner was at home but not present in the room sometimes causing the health care worker to feel like their presence was an intrusion when they visited the mother and child health care providers also experienced difficulties in communicating with the partners there have been cases where a partner has left because of my presence saying its okay youre just going to say bad things about me anyway and i alienated him by taking the mothers side category 2 difficulty in talking face to face against the background of physical distancing during the covid19 pandemic mothers sometimes refused to allow home visits and health care professionals could not talk facetoface so the meeting took place over the phone instead this category comprised two subcategories in the early stages of the covid19 pandemic the disease was considered highly contagious and potentially fatal so visits were considered to increase the risk of infection therefore an increasing number of mothers did not wish to receive home visits health care providers found it difficult and challenging to assess maternal and child health through telephone interviews since covid19 i have been getting a lot of rejections when i call to make an appointment for a visit at the beginning of the state of emergency i didnt visit their home and instead talked with mothers on the phone but it was very difficult for me to judge the severity of the situation because i couldnt see her face and couldnt ask her questions from the epds in detail the mother was extremely sensitive to the possibility of getting covid19 from the health care worker during the visit when i placed my work bag on the doorstep they complained that it was dirty category 3 inability to offer family assistance the health care professionals were concerned about mothers who were unable to return to their hometown to prepare for childbirth or could not ask their own mother for help because of the covid19 pandemic and the calls to refrain from travel between prefectures also some postpartum care facilities had stopped accepting mothers at times and the health care professionals felt that they could no longer encourage mothers to get help from family members or health care facilities at a time when the mothers should be getting some rest this category comprised three subcategories in japan mothers often give birth and spend the postpartum period at or near their parents home when the covid19 pandemic made it difficult for mothers and children to travel and there were no family members nearby to take care of the children the mothers were considered to be at higher risk of childcare stress it is difficult to find a place to leave the children for some time so that the mother can rest unless you have a family member who can take care of them and this is one of the unfortunate aspects of the covid19 pandemic the covid19 pandemic prevented mothers and children from staying overnight because home care was encouraged and postpartum care facilities were closed major facilities were closed for about 6 months in august so there were people who wanted to stay overnight and rest during this time but were unable to do so the covid19 pandemic placed a greater burden on mothers to take care of their children at night by themselves when there were no family members nearby or the facility was closed healthcare providers experienced difficulties in providing support for them it is a great burden to have to take care of the children by myself at night and they cannot sleep its not easy unless you have a family member that you can leave your child with even if we introduce them to the support services we cannot take over childcare for them it does not eliminate their burden category 4 anxiety about being a source of infection healthcare professionals were under increasing pressure not to be a source of infection during home visits in particular they felt anxious about holding the baby and providing breastfeeding care that involved direct contact this category comprised three subcategories during home visits health care workers were stressed because they had to take care not to infect the mother and child medical workers were more stressed about being a source of infection than being infected themselves and i felt the same stress although the health of the mother and child is usually investigated through contact with the child at home the health care workers felt stressed because they could not make contact so as to prevent the spread of covid19 i couldnt have direct contact with children such as holding the infant or their siblings during the home visit like i used to normally i would say its ok mom ive got him and i would hold him while recording or while having her fill out the edinburgh questionnaire but i couldnt do that at the time of the visit health care workers were concerned about the extent to which they should take infection control measures for covid19 i was told that my bag was dirty when i put it in the doorway relationships among the categories it was difficult to examine the relationships between categories through code relationship analysis using maxqda because the categories were too close together therefore it was necessary to review and discuss the verbatim transcripts codes and subcategories to analyze the relationships between categories authors analyzed the data while considered similarities and dissimilarities not conducting a simple descriptive analysis based on the reviews and discussions the most important categories for health care providers visiting the home were considered to be category 2 and category 4 in other words the factors in categories 2 and 4 were considered to have made the visit more difficult and were thought to interact and influence the other two categories with category 1 those three categories are thought to ultimately affect category 3 discussion this study revealed four categories of difficulties for healthcare professionals who visited families with infants to screen for postpartum depression during the covid19 pandemic lack of support for partners inability to meet and talk directly with mothers inability to offer family assistance and anxiety about being a source of infection the relationships between the categories suggested that categories 2 and 4 in particular which were new concerns caused by the covid19 pandemic were top of mind and were thought to affect the other categories along with the new finding that mothers felt unsupported by their partners which had not been discussed during visits before the ultimate finding was that they felt difficulties regarding the lack of support for their families in a japanese study the incidence of male depression at 1 and 6 months postpartum was 112 and 12 respectively which is about the same as that of maternal postpartum depression 24 although healthcare providers were aware that the incidence of male postpartum depression was increasing they found it difficult to assess the mental health of the partners some studies have shown that the epds is a useful measure of postpartum depression in fathers 25 but there is still no consensus on the cutoff value in the future it will be necessary to establish a cutoff value for paternal edps in accordance with the situation in each country and to use the same standard to evaluate the situation and take appropriate countermeasures in a metaanalysis of five qualitative studies kido et al reported that support for fathers who are aware of postpartum depression is inadequate that male gender is a barrier to seeking help and that fatherhood motivates fathers to take action to overcome postpartum depression 26 takehara et al also pointed to the lack of easy contact with fathers after childbirth and the rapidly increasing role expected of fathers after childbirth in the social context as obstacles to assessing postpartum depression in fathers 27 as expectations for paternal participation in childcare continue to increase everyone must recognize that postpartum depression can occur in fathers as well as in mothers and efforts must be made to provide early screenings and interventions using appropriate assessment instruments such as the epds during home visits in the present study mothers talked at length about not only childcare but also things they would normally discuss with friends tsuno et al reported that a lack of formal support from health care professionals as well as a lack informal support from family and friends was associated with postpartum depression during the pandemic 18 this suggests that health care professionals may be required to provide emotional support for mothers as well as informational support such as how to breastfeed and how to respond to crying even in a situation where it is difficult to go out freely due to the pandemic ongoing efforts are needed to prevent mothers from isolating themselves including home visits infant counseling services and maintaining opportunities to interact with other mothers whether face to face or by using sns andor video chat services during the covid19 pandemic home visit services were difficult to perform and consultations were sometimes conducted by telephone isaka et al reported that 15 of women who gave birth between january and october 2020 refused home visits 16 however home visits are a valuable opportunity to meet both the mother and child at home and assess the risk of postpartum depression and child maltreatment 28 although phone calls email and social networking services might play an increasingly important role it is important to encourage mothers to allow home visits even during a pandemic in the present study some participants felt stressed by having to refrain from direct contact with the children during home visits which they routinely had before the pandemic as well as refraining from providing breastfeeding care they indicated a conflict between their desire to lighten the mothers burden by holding the children and sympathizing with the mothers feelings even if for only a short time and the pressure to prioritize infection control measures healthcare professionals have the requisite knowledge to support mothers and children during the postpartum period for example ensuring adequate sleep after childbirth is important for the mothers physical and mental health after childbirth breastfeeding continues every 3 h and sleep deprivation is common some studies have reported that sleep disturbances sleep quality and daytime arousal difficulties are associated with depression at 1 month postpartum 29 however during the pandemic health care workers could not support mother to introduce mothers to facilities where they could rest because these facilities were closed therefore health care workers have experienced anxiety and feelings of helplessness because of the pandemic and it may be necessary to provide them with both physical and psychological support health care professionals involved in mental health support for mothers are likely to experience mental fatigue which is known as empathy fatigue as a result of their efforts to listen to narratives and support feelings in diverse cases 30 in providing postpartum mental health support it may be necessary to increase opportunities to interact with and listen to mothers at various places in the community rather than leaving this role solely to health care professionals who make home visits the present findings suggest that the creation of a system in which a wide variety of actors including medical institutions and local childcare circles provide multiple layers of care for mothers and children may prevent isolation in mothers and their children reduce the psychological burden on the health care professionals who support them and contribute to safe and secure childrearing in the community not only during the pandemic but also in the postpandemic world 31 we believe that support for medical professionals will lead to better support for mothers in the future additional surveys of mothers should be conducted to determine what support is needed in the community limitations to our knowledge this is the first study to investigate the difficulties of health care professionals in supporting mothers and children during the covid19 pandemic the perspectives identified in this study could be applied to postpandemic support some limitations exist in this study this study was based on group interviews with 13 health care professionals working in one municipality in the kanto region of japan and thus the data are biased by the population size and regional characteristics of the municipality additional studies targeting health care professionals in other municipalities are needed in the future in addition because this study is based on interviews conducted from november to december 2021 it is possible that the difficulties experienced by health care professionals will change as the prevalence of covid19 changes further research should be conducted over the long term conclusion this study identified difficulties faced by health care professionals in supporting mothers and infants in the community during the covid19 pandemic although these difficulties may have manifested during the pandemic they may provide an important perspective for postpartum mental health support even after the pandemic ends therefore it seems necessary for visiting professionals to receive mental health support through multidisciplinary collaboration a novel aspect of this study suggests that better postpartum care would be realized by providing support that addresses the difficulties and challenges faced by the health care professionals who provide postpartum support for mothers in addition the findings of this study suggest the importance of collaboration among medical professionals and multidisciplinary professionals in improving postpartum care in the community definition of terms terms used in this study and their definitions are listed in table 4 in our interviews the mothers used a variety of names for their partners with whom they shared responsibility for the care of their children including father dad and husband in this study all of these names were unified under the term partners konnichiwa akachan jigyo a welfare program implemented by each municipality in which home visits are made to families with infants within 4 months of birth 9 edinburgh postpartum depression scale a set of 10 screening questions that can indicate whether a mother has the symptoms common in women with depression and anxiety during pregnancy and in the year following the birth of a child 1011 satogaeri bunben the traditional approach to childbirth in japan list of abbreviations mothers return to their parents home to prepare for childbirth and remain there to receive support while recovering physically and psychologically after giving birth 15 data availability the datasets generated andor analyzed during the current study are not publicly available in order to protect participants coding frames and the steps involved in the analysis are available from the corresponding author on reasonable request competing interest the authors declare that they have no competing interests

background postpartum depression is a risk factor for suicide and maltreatment of children and its early detection and appropriate intervention are issues to be resolved in japan local governments are working to detect postpartum depression early by conducting home visits to families with infants within 4 months postpartum but homevisit professionals have faced new difficulties due to the coronavirus disease 2019 covid19 pandemic that started in 2020 the purpose of this study was to clarify the difficulties experienced by health care professionals who perform home visits to screen for postpartum depression methods focusgroup interviews were conducted during the covid19 pandemic with health care professionals n 13 who make postpartum home visits to families with infants within 4 months data were analyzed using thematic analysisfour main categories were identified that describe the difficulties experienced by health care professionals lack of support for partners difficulty in talking facetoface inability to offer family assistance and anxiety about being a source of infection conclusions this study shed light on the difficulties faced by professionals in supporting mothers and children in the community during the covid19 pandemic although these difficulties were considered to have become apparent during the pandemic the results may offer an important perspective for postpartum mental health support even after the pandemic ends accordingly it may be necessary for these professionals to receive supported through multidisciplinary collaboration in order to improve postpartum care in the community

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introduction over 11 billion people smoked cigarettes in 2015 and regardless of the antismoking international effort the number of people who are continue to smoke is increasing globally 1 smoking is one of leading preventable causes of death that is each year six million people die as a direct result of cigarette smoking 1 smoking is also associated with cancer cardiovascular problems respiratory problems and stroke 2 the magnitude of negative consequences on younger populations are more severe while including the above mentioned health problems smoking also impairs young peoples physical fitness in terms of performance and stamina and increase their likelihood of substance dependency and abuse 3 smoking is also linked to the earlier onset of mental illness and higher rates of smoking are also found in people who have a mental illness which leads to significant comorbidities 4 oman is a developed county in southwest asia with a total population of 45 million people and almost half are expatriates 5 the health care system of oman is developed and it has improved significantly since 1970 as extraordinary efforts have been exerted to improve the general health of the omani population however smoking has received less attention compared with other health problems such cardiovascular disease diabetes and cancer 6 that is although smoking is one of leading causes of death and one which is linked to the development of many diseases the actual magnitude of the problem is not clear in oman the last national survey on smoking conducted in oman was in 2004 the results showed that around 7 of omani population were cigarette smokers 7 however the percentage has increased to 11 of total omani population in 2015 and this rate is predicted to double by 2025 though the report did not comment on the likely reasons 8 the who alludes to the importance of conducting a national survey every 5 years to ascertain rates of smoking in young adults but in 2015 there was no any national surveys conducted 8 this research aimed to redress this issue and respond to who call to conduct ongoing surveys in this area one method of targeting young adults is to identify the prevalence of smoking among university students previous studies showed that the prevalence of smoking among university students varied across countries in kuwait 42 of total university students selfreported that they were smokers 9 in saudi arabia the prevalence ranged from 30 to 35 among male students 1011 another study from jordan showed similar results to previous studies conducted in saudi arabia 12 given the percentage of university students who are smokers exploring the knowledge and attitude toward smoking to this age group is required commencing university is a transition time when many young adults move from the family home to more independent lifestyles and liberal environments in this critical transition life period students may be exposed for the first time or experience peer pressure to start new social experiences such as smoking however there are no current epidemiological studies that explore the magnitude of the problem between omani university students as clearly stated in who last report only the prevalence of smoking among adult population in fact who recommends clearly conducting study on youth population aim of study the aim of this research was to assess the prevalence of smoking and associated sociodemographic and economic factors among university students in oman and examine students knowledge about and attitudes towards smoking methods design a crosssectional descriptive design was utilized as this design is useful to generate a snapshot of information in a short period of time the research was approved by the research ethics committees at sultan qaboos university nizwa university and the university of buraimi the inclusion criteria for the research were omani students registered at one of the above universities who provided informed consent to participate in the research following ethics approval random lists of students and their contact information were generated by the deanship of admission and registration at each university an email including general information about the study an informed consent statement and the contact information of the research assistants was sent to students by the public relations and information department in respective universities students who were interested in participating contacted the ras who answered questions the students had and organized a convenient meeting time on campus for the student to complete the surveys prior to completing the surveys participants were provided with an information sheet and signed a consent form when participants completed the survey they put it in a sealed envelope and placed in in the survey box no identifying information was collected and data will be presented in aggregate to maintain confidentiality setting sultan qaboos university nizwa university and the university of buraimi are in different geographical areas of oman and students who attend the campuses come from all over oman they were chosen to ensure the heterogeneity of the sample squ is the only governmental university located in the capital city of oman and established in 1986 has around 16000 students nu is a nonprofit private university established in 2005 located in nizwa ad dakhiliyah region has approximately 6000 students 13 uob is a private university established in 2004 located in the al buraimi governorate in the northern part of oman with 2100 students 13 sample proportionate random sampling technique was used to recruit participants in the study the total number of students at the squ nu and uob was approximately 24100 students in order to calculate the sample size slovens formula was used n n where n number of samples n total population and e margin of error which resulted in an n 393 a random sample of 400 students were used for this study a random sample of all students in squ nu and uob who met the inclusion criteria and agreed to take part in the study were included to ensure representativeness a 66 25 and 9 of students at squ nu and uob was chosen from each respective university therefore 264 students were randomly selected from squ 100 students were randomly selected from nu and 36 students were randomly selected from uob questionnaire and measures the research team member designed and developed a new survey based on the previous literature and wellknown global surveys which are available in public domains the global adult tobacco survey version 21 14 global youth tobacco survey 15 california adult tobacco survey 16 and youth tobacco survey 17 the survey included information about participants demographics and past history of smoking knowledge survey and positive attitudes towards smoking survey the knowledge survey consisted of 16 items with yes or no answers the correct answer received one mark and wrong answer received zero mark higher scores meant higher knowledge about smoking examples of knowledge questions were smoking increases the risk of cardiovascular problems and smoking increases the risk of having a premature baby the maximum score that could be obtained was 16 the attitude survey contained 12 positive statements about smoking with yes no response for example smoking increases selfesteem people who smoke are more attractive and smoking helps you to relax for each statement answered yes one mark was given to the participants higher score meant more positive attitude toward smoking the maximum score that could be obtained was 12 one professor of public health and three nursing professors to obtain face reviewed the developed survey to obtain face and content validity to ensure the survey was free of typographical errors reliability tests were conducted for both of the knowledge and attitude scales cronbachs alpha was 0818 for the16items knowledge survey and 0896 for the 12items attitude survey analysis data were entered into spss program for the analysis descriptive statistics were used such as frequency means and standard deviations to describe sample characteristics and other factors inferential statistics used included independent ttest and chisquare to draw conclusions about variables under examination the difference between means of age knowledge score attitude score years spent in the university student income day and family members who are smoking were analysed using ttest the remaining factors such as gender marital status location college fathers level of education and mothers level of education were analysed using chisquare a pvalue ≤ 005 was considered to be statistically significant results four hundred and one students completed the survey the mean age of participants was 216 years around two third of students were males 235 and the majority were single 378 one third of the students were from college of art and social science 123 the majority of students were not smokers 364 the prevalence rate of smoking was 90 see table 1 for more results independent ttest results revealed a significant difference in years spent in the university student incomeday family members who were smokers knowledge score and attitude score students who were nonsmokers had higher knowledge scores and a less positive attitude towards smoking scores table 2 details these results chisquare analyses were used to compare smokers and nonsmokers in relation to the students characteristics including gender marital status location college fathers level of education and mothers level of education a significant difference was found in relation to gender place of living and if they had received medical advice discussion the aim of this study was to assess the prevalence of smoking associated factors knowledge and attitudes towards smoking among university students in oman our study revealed that 90 of the students were smokers which is a smaller proportion compared to similar populations in other neighbouring countries in saudi arabia between 16 18 and 17 19 of university students were smokers in bahrain 13 were daily smokers 20 in united arab emirates 15 and in kuwait 46 were reported to be smokers 21 when comparing the results of the current study with the previous studies conducted in oman among university students the prevalence was slightly reduced from 101 22 the results of the current study were expected in omani context because the ministry of health in oman in collaboration with who has created a national health plan with several interventional strategies to reduce the incidence of smoking among the omani people this national plan includes a comprehensive smoking control program increasing taxes on smoking and banning of smoking cigarettes in enclosed public places in addition in 2019 oman also hosted a workshop on implementing tobacco taxes in countries of the whos eastern mediterranean region to discuss and agree upon a way forward to implement national tobacco taxation policies universities are complying with the public regulations of banning smoking in buildings and public places however universities need to promote smoking cessation clinics initiate antismoking campaigns and start health promoting antismoking clinics in addition universities and in their health elective courses need to increase the awareness of students about the negative health consequences of smoking interestingly our results showed that most of the students held negative attitudes towards smoking and had a good level of knowledge about smoking which might also explain the low rate of smokers in our sample positive attitudes towards smoking have been shown to be associated with commencing tobacco smoking in a longitudinal study among university students 25 however contrary to our findings the same study could not find a significant association between the students knowledge level and the commencement of smoking therefore further longitudinal studies in oman could add to the existing body of knowledge a study conducted among university students also found that smokers had negative attitudes towards policy aimed to reduce students smoking such as banning of smoking in public areas on campus 26 musmar 26 showed further that smokers were less likely to acknowledge education about the harmful effects of smoking these findings taken together with the results from current study strengthen the need for health promoting and strengthening campaigns to sustain and increase the existing negative attitudes towards smoking in omani university students in addition a clear action plan needs to be developed by the healthcare authorities and or public health sector to continue to educate and change attitudes to reduce levels of smoking another interesting finding reported in this study was the significant differences between smokers and nonsmokers regarding student income per day and family members who are smoking similar findings were reported in a qualitative study addressing the factors that motivate male university students to smoke in kuwait 27 the study addressed family social and psychological factors to be motivational to smoke 27 thus an effective and sustainable health education program should be planned to take into consideration the possible associated factors with smoking initiation and positive attitudes towards smoking in addition policy makers in ministry of health and public health sector in collaboration with university administration should introduce a clear smoking prevention plan such a program should be introduced at a younger age to promote healthy living additionally gender was one of the factors associated with smoking status in the current study compared to studies conducted in similar populations ie university students in the middle east the gender differences in our study are in line with the smoking trends in the neighboring countries in musmar 26 the rate of male students who were smoking was significantly higher compared to their female counterparts furthermore in a review study about the prevalence of smoking in university students the authors found that the smoking prevalence among male students was significantly higher than female students in several arab countries such as saudi arabia bahrain yemen jordan egypt tunisia and palestine 21 the significant differences in smoking among males and females could be explained in the light of the nature of the middle eastern region with its customs and traditions according to which smoking among females is still culturally unacceptable this calls for genderspecific approaches to smoking interventions among omani university students the findings of the current study give a general background information and emphasis on the need for decision makers in oman to develop new strategies and educational programs that help in reducing the prevalence of smoking among university students limitation a limitation of this study is the nature of the descriptive point prevalence study that measures the actual prevalence in a certain point in time but does not explain causes or relations ie only associations but not the direction of the association however this type of study is needed to generate hypotheses construct research questions and guide policy makers as well as researchers in further steps conclusions a low rate of smokers in this population is a good sign of the effectiveness of the public health policies followed in oman however predictions suggest this trend of low rates of smoking may increase due to the influences of peers family members and the psychological factors thus strategies that promote a sustainable healthy living need to be developed and implemented in younger populations especially university students additionally gender was one of the factors associated with smoking status which calls for genderspecific approaches to smoking interventions among omani university students further research with a qualitative approach to investigate smoking initiation could be of significant importance to support the current study findings and give a more nuanced picture of the smoking habits among university students author contributions all authors contributed to the study conception and design material preparation data collection and analysis were performed by oao the first draft of the manuscript was written by oao and ak and all authors commented on previous versions of the manuscript all authors read and approved the final manuscript conflict of interest no authors of this paper have any conflicts of interest ethics approval this study was performed in line with the principles of the declaration of helsinki approval was granted by the ethics committees of sultan qaboos university nizwa university and the university of buraimi informed consent informed consent was obtained from all individual participants included in the study open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit iveco mmons orglicen sesby40 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

this study aimed to assess the prevalence of smoking and associated sociodemographic and economic factors as well as students knowledge about and attitudes towards smoking among university students in oman a proportionate random sampling technique recruited 401 students from three universities in a crosssectional study the prevalence of smoking was 90 significant differences in gender place of residence if participants had received medical advice years spent at the university student incomeday family members who smoked knowledge and attitude scores were identified universities in collaboration with health care providers should be leading the development of strategies to reduce the prevalence of smoking and to sustain the current knowledge and attitude towards smoking genderspecific approaches to smoking interventions need to be developed

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introduction datasets of largescale online behavior and digital traces are growing more sensitive as privacy expectations and regulations mature to address such concerns data providers are turning to differential privacy to balance largescale data releases with maintaining privacy guarantees for individuals whose data may be included in these releases differential privacy techniques operate by injecting noise into observations to prevent identification of individuals in these datasets for an introduction to these methods these protections come at a cost however as standard analyses may produce biased or erroneous results if they do not account for such protections this issue is particularly evident in the release of the facebook privacy protected full urls dataset referred to as the condor dataset where facebook and the ss1 consortium have released a massive collection of 635 million links shared on the facebook platform along with differentialprivacyprotected engagement data on age gender location and political preference condor is the largest dataset of linklevel engagement released to date and holds marked potential for studying largescale online behaviors but researchers lack guidance in and examples of methods that account for differential privacy protections this paper provides this guidance by 1 examining a simple weightedaverage metric for calculating ideological positions of audiences for web domains1 based on linksharing in facebook in the presence of differentialprivacy protections 2 showing how differential privacy impacts this metric 3 establishing bounds on how this metric should be used and 4 validating this metric against similar domainlevel sharingbased measures while similar metrics have been proposed those efforts rely on highly sensitive data such as internal facebook data or twitter profiles aligned with sensitive voterfile information in contrast this papers metric can be calculated solely from this differentially private public dataset after establishing constraints for our differentialprivacyresilient metric we use it to extract novel insights about individual hyperlinks where sparsity issues have forced previous approaches to use domainlevel measures we then assess how different types of engagementviews and likesimpact our measures for individual hyperlinks we estimate distributions of linklevel ideology measures for several thousand individual links across six popular domains including youtubecom providing insight into longstanding questions about partisan audiences on that platform for different types of engagement we measure differences in domains audience ideologies using linksharing viewing and liking behaviors also answering open questions about consistency in measurement across engagement types results show no significant deviation in domainlevel estimates across these activitiesthough a domains viewing audience is on average more moderate than its sharing or liking audiences given the commercial value of viewing data in online platforms this result is particularly encouraging for the generalizability of sharebased studies and for future efforts that leverage protected versions of this sensitive data this works core contributions are • a demonstration of how a simple metric for estimating ideology of a domains audience can be made robust to differential privacy protections • an examination of linklevel distributions of ideology across six major news sources and • new insight into how varied forms of engagement impact audience ideology estimates related work this paper engages with two main communities first a large body of research exists on inferring ideology of audiences in studies of media bias and polarization especially in online spaces which both motivates this work and provides sources for validation second much of the data that could be useful for similar studies is often restricted and sensitive recent work has explored methods for providing data protections of such sensitive data while still enabling inference on this data which directly informs our work before describing contributions to these communities we first provide an overview of differential privacy to situate this work a brief primer on differential privacy at its core differential privacy is an approach to collecting and disseminating aggregate statistics in a way that guarantees some level of privacy for individuals whose data is used to generate these statistics while wood et al provides an overview of differential privacy for nontechnical audiences such protections generally provide a form of plausible deniability for individuals whose data is included in these statistics this deniability comes from the property that a thirdparty cannot learn anything about a single individual whose data contributes to these statistics that could not be learned if that individuals data were excluded hence an individual could claim their data was never included in the released statistics at all allowing them to deny potential allegations derived from the data digital trace data can therefore benefit from applications of differential privacy as largescale aggregate datasets can be released in privacyprotected forms that reduce potential harm to the populations from which the data is collected d orazio honaker and king these protections are also consistent with calls for and regulations on enhanced protections of digital consumer data and groups like the us census bureau are using similar ways to protect sensitive data these protections are generally applied by adding noise into the computations of aggregate statistics researchers can tune characteristics of this noise to quantify potential privacy loss and by tracking this loss over subsequent dataset releases those creating these datasets can maintain privacy guarantees characteristics of this noise can be shared as part of the release process without risking these privacy guarantees so researchers can account for this noise without identifying individuals within the dataset in the context of the condor dataset facebook bounds privacy loss by adding noise to the aggregated engagement statistics prior to releasing the dataset to external researchers that is if a hyperlink has been shared x times in a given month facebook adds noise ϵ drawn from a gaussian distribution to this value and external researchers only ever see x ϵ measuring political ideology methods for estimating ideology partisan lean media slant or similar aspects of information sources are wellstudied and generally fall into one of two categories contentor homophilybased approaches contentbased approaches generally analyze language while homophilybased methods propagate individuals ideological preferences to the information sources these individuals share or consume contentbased analyses like the study of media slant in gentzkow and shapiro or media bias in budak goel and rao are powerful but require content analysis and either manual assessment or information about political preferences of people sharing that content to learn mappings of particular language to political preference in contrast while homophilybased methods need information about political preferences they do not require analysis of actual content and instead rely on interactions among nodes in a network through these interactions one can propagate political preferences to neighboring nodes making these methods particularly amenable to algorithmic assessment in online social networks such interactions are often computationally cheap to collect through apis or found data making these approaches popular in research homophilybased methods for inferring political ideology have been used to measure onlineoffline ideological segregation diversity in online news ideological biases in search engines and even political lean of disinformation agents despite the clear utility and popularity of such homophilybased approaches when these methods use social media data to measure ideology of a news sources or web domains audience as in robertson et al golovchenko et al eady et al and othersthey commonly rely on easily collectable sharing behavior while sharing behavior is easy to collect from sources like twitter and reddit prior research on social media spaces and online communities shows that the vast majority of users on the platform do not actively share or produce content benevenuto et al in particular suggests that 92 of all behavior in one social network was comprised of content viewing alone which does not produce collectable artifacts in many public apis data about these viewing behaviors however is commercially sensitive and most social media platforms do not make this data publicly available for studies of viewing behavior in facebook for example up to the release of ss1s condor dataset one has had to rely on researchers employed by facebook as in bakshy messing and adamic or partner with researchers at facebook this reliance on content production and sharing leads to a problematic implication a media sources ideological slant is significantly affected by the sources audience and as sharebased metrics omit activity from a significant portion of the viewing audience measures of the media sources audience may differ significantly from the true distribution gentzkow and shapiro a unique aspect of the condor dataset provided by ss1 however is that it provides engagement data across both sharing and viewing behaviors binned across several politicalpreference buckets hence the work in this paper can shed some needed light on the differences in estimates based on shares versus views that is by first comparing results from our sharebased audience ideology metric to existing work in this area we can validate our metric despite the privacyprotecting noise injected into condor observations then by comparing results from our sharebased estimator to estimators based on views and indeed other behavior such as facebooks like reaction which is similar to twitters favorite affordance we can evaluate whether differences in shareand viewbased estimates differ significantly inference and protected data while the above context on measures of media bias and audience ideology show a clear need for understanding the impacts of shareversusviewbased metrics as mentioned view data is both commercially sensitive and highly private facebook has endeavored to help researchers in this need by releasing the condor dataset and protecting it with differentially private noise as described in messing et al while works such as d orazio honaker and king and evans and king outline how differential privacy can support inference in social sciences how these protections impact on researcher utility remains an open question evans and king even shows ignoring differential privacy can lead to unpredictable biases in results including biasing estimated effects towards zero or in some particularly problematic cases inverting the sign of the estimates despite these risks evans and king shows corrections are feasible in certain scenarios as the noise added to data for establishing differential privacy guarantees is equivalent to increasing standard measurement error and for linear systems one can correct for noise if details of the noisegenerating distribution are known for nonlinear systems like the weightedaverage metric we present however analytically based corrections are not readily available we instead build on evans and king which outlines the context in which bias in a ratio metric can be bounded evans and king claims that if the noise introduced is generally much smaller than true observations bias in the noisy metric is minimal while this result is valuable no guidance is provided regarding how large observations should be relative to noise nor how to evaluate whether one is in this regime hence this paper provides this muchneeded guidance for using these noisy observations in the condor dataset to study media and ideology in a robust manner we further validate these methods against extant results where such privacy protections are not in place condor the facebook privacy protected full urls dataset as a brief overview the privacy protected full urls dataset provided to academic researchers by facebook and the ss1 consortium is a largescale collection of urls and associated engagement data for 63574836 hyperlinks shared on the facebook platform this dataset exists to provide researchers new insight into how individuals engage with hyperlinks on the facebook platform while simultaneously maintaining strong privacy guarantees for facebook users for a url to be included in this dataset it must have been publicly shared by approximately 100 unique individuals for more details as of this writing the dataset is on its ninth iteration and contains monthly engagement metrics for all months between 1 january 2017 and 31 december 2021 for each of these urls the dataset contains counts for 11 actions one can take on the facebook platform broken down by month and audience demographics these demographics cover an individuals country age and gender from one of 45 countries seven age groups and three gender groups in the us condor further decomposes these counts across six bins representing individuallevel political preference using a political page affinity metric a homophilybased measure defined by barberá et al and described in messing et al ppa measures an individuals political ideology on a scale b ∈ 2 1 0 1 2 with an additional bin for individuals whose ppa is unknownwe exclude this sixth group from our analyses in this manner the condor dataset contains makes available highly sensitive but valuable engagement data for large volumes of online information sharing and consumption behavior given the sensitivity of this data and to protect users of the facebook platform from potential deidentification researchers using the condor dataset do not have direct access to the raw monthly counts of these activities instead researchers can only observe counts of these activities after facebook has added zerocentered gaussian noise to them in accordance with zeroconcentrated differential privacy by controlling the amount of noise relative to the amount of engagement across these demographic bins condor provides privacy guarantees about the probability of an individual persons single action being attributed to that person that is more noise can be injected into counts of views compared to counts of shares or clicks while noise added across a single action comes from the same normal distribution table 1 summary of notation in audiencelevel ideology estimates x denotes estimates of x using differentially private data for this work we focus on urls shared primarily in the us all access to this data is allowed through the ss1 approval process and is conducted on the facebook open research and transparency platform a robust metric for audience ideology we now turn to a metric for estimating the ideology of a domains audience from this dataset prior work on media slant has shown audiences political preferences have a marked relationship with the message topic selection and framing of news sources in this context bakshy messing and adamic propose a homophilybased metric of the degree to which a news article is aligned with a partisan audience by averaging the ideological affiliation of each user who shared the article in the differentialprivacyprotected condor dataset we can replicate this metric at the web domain level by measuring the average political ideology of the individuals who share content from this domain table 1 summarizes the notation we use in defining our version of this metric while condor includes engagement metrics we focus on sharing for consistent comparison with other work on ideology estimation as condor provides engagement data for each ppa bin we can interpret these counts as the frequencies for which an individual who is very liberal liberal etc has engaged with this content to estimate a domains audience ideology ζ d from this ppa metric we calculate the weighted average across these five ppa bins omitting the sixth ppa bin that contains audience engagement with unknown ideological affinity eq 1 shows this metric as the product of each ppa value with the count of individuals who have shared that domain and have that ppa value in eq 1 s b represents the number of individuals with the ppa value b who have shared the domain d in condor however engagement frequencies are at the urlhyperlink ℓ level not the domain level so we must first aggregate s b over all links ℓ in domain d as shown in eq 2 ζ d 1 b s b b∈ 22 b • s b s b ℓ∈d s b in the absence of differentially private data protections eq 1 is fundamentally the same metric as in bakshy messing and adamic and is similar to robertson et al with the introduction of zerocentered gaussian noise however these metrics are illbehaved and can result in discontinuities as we explain below how noise impacts this metric analytically while the metric ζ d in eq 1 is a straightforward calculation differential privacy protections preclude observing the actual number of shares for a given ppa value directly instead we observe a noised version of this value shown in eq 3 where ϵ sb is drawn from a zerocentered gaussian distribution with standard deviation σ this σ is constant for a single action and reported in the condor codebook hence when calculating the number of individuals in ppa bin b who have shared a domain d we can only construct a noisy estimate of this quantity s b substituting this value into eq 1 yields a noisy estimate of domainlevel ideology ζ d as shown in eq 7 s b s b ϵ sb s b ℓ∈d s b ℓ∈d ϵ sb s b ϵ sb ζ d 1 b s b b∈ 22 b • s b critically the ratio in eq 7 is illbehaved when the magnitudes of actual shares s b and the noise ϵ sb are similar in such cases because the gaussian noise is zerocentered and can be negative the denominator can approach zero which inflates the metric this scenario can also lead to pathological cases in which denominator is exactly zero resulting in discontinuities in the ideology estimate given the number of urls in the dataset these rare cases occur sufficiently often as to be problematic analytically eq 7 can be viewed as a ratio of gaussian distributions but these pathological cases results in this ratio having a cauchy distribution which has an undefined expected value it is consequently difficult to isolate and correct for bias introduced by differentially private noise analytically fortunately other work has examined this bias and we rely on hayya armstrong and gressis evans et al and evans and king for their discussion of weighted averages in the face of noise in particular if counts are normally distributed we could treat this instance as a ratio of correlated noncentral normal distributions and use the result from hayya armstrong and gressis to find the expected value of this ratio in that case as long as mean of the denominators distribution is sufficiently large compared to the mean of numerator bias in this expectation goes to zero while we cannot assume normally distributed counts in this dataset for a discussion of lognormal distributions in social media engagement data accounting for bias when the denominator is sufficiently large is supported by evans and king evans and king relies on taylor approximation to expand a ratio of noised observations leading to an upper bound on potential bias in this estimate shown in eq 8 following from eq 2 of evans and king where we replace k with the number of ppa bins specifically as long as the number of shares s b is sufficiently greater than the variance of the noise added eq 8 goes to zero restated as long as s b σ s or equivalently s b σ s 1 bias in this metric should be negligible borrowing from signal processing we refer to this ratio of engagement to noise as the signaltonoise ratio defined in 9 bias 4 • σ 2 2 sn r 2 σ 2 impacts of noise via simulation as we show above for a sufficiently high snr bias in our metric is negligible but that analysis does not tell us what a sufficientsnr regime might be we thus turn to simulation to evaluate potential bias in the environment specific to the condor dataset and construct two experiments first we evaluate whether the environment observed for popular domains in the condor dataset are sufficient for our metric to be unbiased second we examine the relationship between snr and bias to get a sense for what levels of snr and observed sharing are necessary to produce tight estimates of political ideology estimating bias for popular domains in the first simulation experiment we test the hypothesis that ζ d ζ d 0 or whether the noise in condor drives a significant difference in our estimates of ideology we perform this analysis after observing engagement data for the top 1 most shared domains in the condor dataset which we select under the expectation that these popular domains achieve the necessary sharetonoise ratio in the alternative case ie that these domains do not have sufficient shares to be in the highsnr regime the noise added to this dataset may overwhelm any useful signal at a high level each run in the simulation starts by drawing ideology scores ζ d for a given number of domain observations n obs for each domain we sample a count of the links to this domain u d from a lognormal distribution and sample linklevel ideology estimates for each link ζ ℓ according to a normal distribution centered at ζ d for this domain we then sample the number of shares for each link s in this domain also from a lognormal distribution and distribute these shares across the five ppa bins according to ζ ℓ this process yields a collection of domains with associated links and shares across ppa bins for each link mirroring the facebook collection prior to noise injection to simulate the noisegenerate process we add noise to each links simulated shares s b using the exact process outlined in the condor codebook we aggregate these linklevel shares up to the domain level and estimate ideology ζ d from these noisy observations comparing this estimate from noisy sharing counts to the actual ideology yields an estimate of the bias added by the differentially private noise parameters for this simulation come from qualitative assessment of the condor dataset and are shown in table 2 we then run the simulation with n sim 100 iterations sampling n obs 100 domains per iteration and calculate the mean bias ζ d ζ d and montecarlo standard error for each iteration simulation results produce an estimated bias of 4006 × 10 5 with a montecarlo standard error of 54940 × 10 5 variance across simulation iterations is also small at 30485 × 10 7 these results shows the proposed estimators bias is neither statistically significant nor is this difference practically significant on the 2 2 scale of ppa a note on aggregation one may be tempted to first estimate ideology by calculating ζ ℓ at the link level and taking the mean across all links in domain d to calculate ζ d which is more consistent with the metric provided in bakshy messing and adamic this approach produces a much higher mc standard error in this case however as the sharing signal in a given link is generally much lower compared to the additive noise than in the aggregate we provide guidance on when such linklevel estimates are reasonable in a later section relationships between snr and bias in the second simulation experiment we examine the relationship between snr and variance in our ideology estimator this experiment fixes the number of links a domain has and varies the number of shares necessary to achieve a target snr defined in eq 9 we run this experiment with two fixed values for the number of links in a domain first setting u d 1024 to evaluate snr for domainlevel aggregates and then setting u d 1 for cases where researchers want to study a single link varying snr on the interval 11024 shows that an sn r ≥ 16 results in tight estimates on ideology regardless of whether we aggregate over many or few links these metrics derive from n sim 500 runs of n obs 100 000 domains with uniformly distributed ideologies for each snr parameter description ζd audiencelevel ideology of a domain d drawn from a threecomponent gaussian mixture model ζ ℓ the mean political page affinity for a given link ℓ ∈ d drawn from n with σ 05 to provide separation between bins ud the number of hyperlinks to domain d for which we have sharing data drawn from a lognormal distribution ln as estimated from the condor dataset s the number of shares for link ℓ drawn from a lognormal distribution ln as observed within the condor dataset s b the number of shares in political page affinity bin b for link ℓ which we allocate from s by drawing 100 samples from n and scaling up σ 075 is chosen so most mass is ±15 from the mean ϵ b noise added in to sharing in political page affinity bin b for domain d drawn from n a remaining question concerns the level of observed sharing needed for tight estimates to this end we have explored the maximal number of observed sharing averaged over several linksharing counts and privacyprotecting noise levels necessary for tight bounds this exploration suggests the relationship between sufficient observed sharing and aggregate noise is linear in loglog space for a fixed snr using this framework we then estimate the relationship between this noise and a target observed sharing volume needed for tight estimates at sn r 16 this model is shown in eq 10 where 16 is the snr 5 3 and 7 are number of ppa bins gender bins and age bins respectively m is the number of months the aggregation covers u d is the number of links over which one is aggregating and σ dp is the noise added for differential privacy this equation for s or the amount of observed sharing allows us to set a lower bound on the volume of observed sharing necessary for stable estimates this model also allows us to vary injected noise σ dp meaning we can estimate the minimum quantity of engagement one should observe for other types of activity in condor as well s ≳ 1578 • audience ideology for popular domains we now use this metric and bounds on sharing to examine the distribution of audience ideologies among facebooks top 1 most popular us domains among politically engaged facebook users this analysis covers 2629 domains out of a possible 2644 as 15 domains were excluded for having insufficient activity to achieve the target snr relative to the number of links u d these excluded domains include soundcloudcom and reverbnationcom which both have high numbers of unique links in condor leading to high differences between observed and needed sharing making their estimates suspect figure 1 presents distributions of our estimated domainlevel ideologies with a selection of domain annotations divided into news and nonnews domains for news domains we select domains that have ratings from the newsguard 2 trust rating service and exist in our top1 set resulting in 1279 newsoriented domains this collection shows a trimodal distribution with traditionally liberal news sources on the left conservative news on the right and more centrist reporting such as cspan around the center for nonnews sites we see many centrally oriented domains are primarily shopping social networking crowdfunding and sports sites whereas nonnews domains in the ideological extremes are primarily activist organizations as our metric captures ideological leans of a domains audience in the context of news sources gentzkow and shapiro suggests this measure should be highly correlated with the slant of these sources for national news like the new york times breitbart etc these sources are consistent with traditionally accepted partisan placement at the local level we find localaffiliate news stations are aligned with more ideologically moderate audiences with kqed in berkeley ca having the most liberal and partisan audience of the local affiliates the national media outlets on the other hand are more wellseparated this alignment among local affiliates is consistent with the literature as berkeley ca leaned heavily liberal in the 2016 presidential election and lafayette la leaned heavily conservative the data also suggests as seen in other work a wider gap between the moderate and conservative components compared to the moderate and liberal components suggesting the conservative media sites are more insulated from mainstream media comparisons to other ideology measures to validate the audience ideology metric calculated from differentially private sharing data we compare our results which uses ratios of shares from registered republicans and democrats twitter accounts we find a significant pearsons correlation ρ 09295 here for 1675 domains our second comparison is with a homophilybased measure introduced by eady et al where we achieve a strong correlation ρ 09386 across 154 domains our third comparison is with the similarly defined ideology scores introduced in bakshy messing and adamic where we find the highest correlation for 112 domains lastly we compare against a contentbased media slant estimate for 16 newspapers analyzed in budak goel and rao where we find our lowest but still strong correlation despite the complexity introduced by differential privacy protections in condor our estimates are strongly correlated across all four of these comparison beyond the most popular domains above we focus on the top 1 of domains as these domains are more likely to exceed the threshold established in eq 10 and because these domains are wellcaptured in other works on audience ideology our method is not restricted to only popular domains however as domains that are shared less often may still have sufficient signal to exceed our threshold eg using eq 10 if we observe a domain with a single link and use only one month of data that domain need only have about 906 observed shares to provide stable estimates as the most recent iteration of the condor dataset contains 363738 domains over five years one may then ask how many of these similarly exceed the thresholds we establish for this stability this quantity is also important for the creators of the condor dataset as it can shed light on the tradeoff between differential privacy protections and data utility in downstream analysis to answer this question we randomly sample 1024 domains from the condor dataset and measure the proportion that exceed the threshold of observed shares in eq 10 for all domains we use the same σ 2 dp 14 value and set m and u d to the number of months for which the domain has data in condor and the number of unique hyperlinks to that domain respectively of these 1024 domains 43 exceed this threshold accounting for the top 42 of the domains in this set in comparison over 994 of the top1 of domains exceed this threshold while this proportion is low that still leaves in excess of 15 thousand domains that will produce stable ideology estimates using the method described above this result also has an important implication for the condor datasets construction more generally while we note a couple of ways one might increase this proportion through relaxing constraints or focusing on linklevel estimates it is also true that the application of differentially private noise to the condor dataset is done with limited insight into the downstream impact this noise has on analyses hence this finding motivates a call to facebook to revisit its privacy budget and investigate the balance between adding noise and reducing utility of this large dataset linklevel audience ideology estimates in the preceding section we have focused on demonstrating the validity of the audienceideology metric by showing the bounds in snr for which ideology estimates are tight and comparing our domainlevel metrics to several extant nondifferentialprivacyprotected datasets this metric is not specific to domainlevel metrics however and is equally amenable to estimating audience ideology at the individual link level as in bakshy messing and adamic this linklevel analysis is a major advantage of the condor dataset as the scale at which it provides these engagement metrics alleviates sparsity issues which are a major barrier to linklevel analyses in other sources that is the condor dataset provides a much larger volume of linklevel data than academic researchers are generally able to access allowing for novel insights into ideological distribu tions across individual links rather than domainlevel aggregates that said noise added to engagement metrics for individual links may be relatively high compared to domainlevel aggregates as many individual links likely do not receive sufficient engagement alone to support ideology estimates using our proposed metric to illustrate this point we estimate audience ideologies for individual links to six popular domains across the ideological spectrum of these domains five are news sources which we order from left to rightliberal to conservative huff post the new york times cspan fox news and breitbart traditionally huff post and the new york times are considered leftleaning sources whereas fox news and breitbart are rightand farright sources in contrast cspan is a nonprofit nonpartisan source that primarily covers the us house of representatives we also include youtube as our sixth domain given its substantial role in the online news ecosystem for each of these domains we calculate audience estimates using the ninth iteration of the condor dataset covering 20172021 and show linklevel distributions for all links in each domain and only for those links with sufficient engagement as estimated by eq 10 ie s 7 014 tables 3a and3b show summaries of these figures as well distributions of audience ideology when we use all links from each domain consistently show extreme variation with youtube showing the widest range from 57600 to 5167 in contrast focusing only on links with with snr 16 yield more stable averages and more informative distributions interestingly links to youtube videos appear symmetrically distributed in their audience ideologies and cspan shows wider variation the remaining four domains traditionally considered partisanleaning exhibit the expected partisan distributions with the majority of links falling on one side of the ideological spectrum some links from these domains do cross the ideological divide though eg 1169 of the links in figure 3b from the new york times have an audience ideology measure ζ ℓ 0 one article in particular i wanted to be a good mom so i got a gun was shared by a solidly rightleaning audience table 3 summary statistics for linklevel audience ideology for six major domains consistent with figure 3 ideology measures using all links exhibits high variance potentially masking useful structure which emerges when we constrain links to those that are sufficiently popular comparing shares likes and views prior sections use sharing as the primary mode of engagement so we can compare against similar methods on facebook and twitter concerns with these measures include 1 sharing as a proxy for viewership and 2 counterattitudinal sharing wherein an individual shares a particular article to criticize it often exposure to information is more important than who is sharing information but sharing activity is more readily available so it is used in place of exposure similarly while prior work shows criticism is one of the primary motivations to share content in political discourse counterattitudinal sharing is relatively rare so it is generally ignored the condor dataset is not limited to sharing though as it contains mea2015whataboutdisney sures of likes views and other activity though the added noise varies for these actions we can therefore compare whether the population sharing a particular domain is significantly different from the population who likes or views this content potentially mitigating concerns around sharebased measures we thus compute audience ideology metrics for 2227 domains across three engagement typessharing viewing and likingand compare them in figure 4 this figure demonstrates limited statistically significant differences in ideological distributions exist among share view and likebased measures supported by a oneway anova test 1899 p 01498 that is in comparing the distributions of inferred domainlevel ideology metrics using the three activity types we see no significant differences in these audienceideology values correlation among all three metrics is also very strong suggesting differences based on engagement are less impactful than the crossmethod analysis shown in figure 2 hence despite potential concerns around sharebased measures as proxies for exposure and counterattitudinal sharing the ideological alignment of audiences sharing viewing and liking these domains are statistically indistinguishable separate from these concerns one may expect differences in the extremes of these ideology distributions as political sharing on facebook is relatively rare we therefore test an alternative measure by taking the absolute value of the ideology metric ζ d to measure potential partisanship rather than liberalconservative ideology comparing this partisanship metric based on shares views and likes shows a more significant difference among these three distributions 1795 p 0001 a posthoc tukey test shows a moderating effect in viewership in that a domains viewing audience appears significantly more moderate than its sharing and liking audiences a note on views we note that the interpretation of views in condor does not directly capture the volume of individuals who have visited and viewed a given url outside of the facebook platform instead the condor codebook defines views as the number of users who viewed a post containing the url that is an individual may view a link outside the facebook platform and this view would not be captured in condors view count conversely an individual may view a post in facebook containing a specific link without visiting the link and this interaction would be captured in condors view countactually visiting the link is captured by the click count while this interpretation omits offplatform engagement condors operationalization of views still captures important networkdriven exposure aspects that other work largely is forced to omit given the commercial sensitivity of this measure hence the result above should be interpreted as the audience exposed to a particular domain within facebook is significantly more moderate the audience that shares and likes that domain threats to validity though the condor dataset is a milestone in the availability and transparency of social media data concerns remain around how such data is collected and protected first the process by which the condor dataset is constructed is opaque to researchers in that parties outside of facebook are not allowed to inspect the code used to select urls or calculate the metrics like ppa as a result researchers are forced to trust that facebooks url selection process is correct likewise researchers are given limited insight into how much data is omitted from the condor dataset because the links do not meet the 100uniqueuser threshold on public shares while internal facebook developers have made some data available about this thresholds relation to the distribution of onplatform links external review of the data preand postapplication of the privacyprotecting noise remains unavailable this latter issue is of particular concern as in the fall of 2021 external researchers identified a flaw in the condor dataset that significantly undercounted engagement in the us this flaw led to condors omission of engagement from us users whose political preferences could not be identified that is while other demographic bins could be null to capture shares from say individuals with an unknown gender no data existed in the dataset for the many users who did not follow sufficient political pages to have an identifiable ppa value though this paper was unaffected by this error and facebook has since corrected this issue the lack of transparency around condors creation and population remains a problem second while the privacy protections applied to the condor dataset serve a crucial purpose how these protections impact research methods remains an open question our proposed metric requires a sufficient level of activity to overcome additive noise which means many important but rare phenomena may be masked consequently domains and links shared among extreme partisan audiences may be included in the dataset but have insufficient signal for useful analyses more worryingly this masking could be asymmetric and result in ideological bias in what links are included to examine this possibility we have examined 500 domainlevel ideology scores from bakshy messing and adamic and assess the overlap between that work and our set using a logistic regression model to assess whether a domains audience ideology scores predict its inclusion in our dataset we find no statistically significant relationship between the two factors for less popular phenomena however this question of bias remains open but a fundamental tension exists between these rare instances and the differential privacy protections as these protections add more noise to these rare instances to prevent identification how these two factors interact needs to be a subject of future work third we stress our ideology metrics measure the audience of a domainlink not the actual content of the domain or link itself while much of the related work in this area makes similar assessments robertson et al it is important to note that content in some of these sites may not be overtly partisan but are more attractive or known to partisan audiences as noted in gentzkow and shapiro the ideological slant of a media outlets audience does affect choices of what that outlet covers and how it does so but this distinction between content and audience is important for interpreting this work ethics and competing interests this works intent is to provide a broader audience with an example for working with social media and digital trace data that has been protected with differential privacy techniques though this work is focused on audience ideology the methods are equally applicable to aggregations across other demographic bins or activities similarly our focus on ideology results in a usoriented analysis as the condor dataset only provides ideologyrelevant ppa assessments for us users while a clear limitation of this work it does hint at the need for broader perspectives on how such leftright scales can be generalized to other national contexts as discussed in lo proksch and gschwend ultimately though teams internal to facebook would have to extend the condor dataset to include pageaffinity scores for nonus audiences regarding ethics in research this work and the condor dataset more generally has some considerations worth noting condors privacy protections provide value in preventing identification of individual users actions on the platform but at the cost of obfuscating rare phenomena vulnerable and minority groups who might be overrepresented in these rare instances are potentially disproportionately impacted by these protections as researchers balance preserving privacy with studying how behaviors on the platform may impact these groups more work is needed to assess how platforms like facebook interact with these populations and how we might study these interactions while still providing a reasonable level of protection for these users while we claim no conflicts of interest for transparency we note that one of the authors of this work has received funding from facebook related to the social science one initiative this funding was not for this work and while facebook has had the opportunity to review this work prior to publication as part of the social science one agreement they do not have authority to prevent publication finally this work was reviewed by university internal review boards as a prerequisite for gaining access to the condor dataset conclusions through the above assessments of our proposed audienceideology measure based on a simple weighted average of online behavior across ideologically grouped audiences this paper presents three core contributions first this measure and its assessment provide guidance for researchers seeking to use differential privacyprotected digital trace data in analyses of online political behaviors which we make more compelling by demonstrating agreement with other published measures that do not have these protections second we extend this work on domainlevel analyses to demonstrate how our proposed metric can provide insights at the individual link level which is often made difficult by concerns of sparsity in other datasets third we contribute to studies of media slant and online political engagement by extending this analysis to other online types of online activity beyond just sharing ie views and likes as condor is the largest dataset of its kind and the primary mode of access to facebook data for researchers unaffiliated with facebook the endogenous metric for audience ideology we providealong with the related insights for ss1 researchers looking to leverage this unique dataset may accelerate research in this space data availability access to the social science one dataset used in this analysis is governed by the research data agreement made available as a joint effort between facebook and the social science one consortium

this paper demonstrates the use of differentially private hyperlinklevel engagement data for measuring ideologies of audiences for web domains individual links or aggregations thereof we examine a simple metric for measuring this ideological position and assess the conditions under which the metric is robust to injected privacypreserving noise this assessment provides insight into and constraints on the level of activity one should observe when applying this metric to privacyprotected data grounding this work is a massive dataset of social media engagement activity provided by facebook and the social science one ss1 consortium where privacypreserving noise has been injected into the data prior to release we validate our ideology measures in this dataset by comparing to similar work on sharingbased homophilyand contentoriented measures where we show consistently high correlation 087 we then apply this metric to individual links from six popular news domains and construct linklevel distributions of audience ideology we further show this estimator is robust to engagement types besides sharing where domainlevel audienceideology assessments based on views and likes show no significant difference compared to sharingbased estimates estimates of partisanship however suggest the viewing audience is more moderate than the audiences who share and like these domains beyond providing thresholds on sufficient activity for measuring audience ideology and comparing three types of engagement this analysis provides a blueprint for ensuring robustness of future work to differential privacy protections

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introduction t he dramatic global rise in the prevalence of childhood obesity over the past 30 years has been described as one of the most serious public health challenges of the 21st century 1 the uk has one of the highest prevalence rates of adult overweight and obesity in europe 2 furthermore substantial rises in prevalence are predicted over the next 30 years 3 obese children are five times more likely to become obese adults 4 and there are known associations between adult obesity and various chronic diseases 3 this has important implications for healthcare provision and the associated increased economic burdens on the national health service 5 in addition to these longterm concerns there are welldocumented adverse health consequences of obesity in childhood itself such as increased risk of hypertension asthma and psychological problems 6 research into childhood overweight and obesity not only focuses on management but also explores potential explanatory factors including parental socioeconomic position 7 low birthweight 8 and behavioural factors such as decreased physical activity and dietary composition 9 current evidence shows increased overweight rates in some uk ethnic minority groups with higher prevalence of excess weight often found in black children compared with white children 9 10 11 findings for children from south asian groups appear to be inconsistent with some studies demonstrating higher overweight and obesity prevalence 912 and others showing similar or lower prevalence when compared with white children 1314 research has also shown variations in overweight prevalence according to sex often with higher prevalence in females 79 however explanations for biological differences suggested in previous literature 15 and behavioural factors related to gender 1516 do not seem to explain the higher prevalence of overweight seen in females across most ethnic groups many of these studies focus on younger children and may indicate other unexplored factors related to sex and ethnicity particularly in older age groups adolescence is an important period where children begin to develop independence over food selection whilst also undergoing changes in body structure that affect body fat 17 while 55 of prepubescent obese children remain obese into adolescence 80 of obese adolescents remain obese into adulthood making adolescence an important period to target public health obesity reduction strategies 4 there are relatively few studies on overweight and obesity in uk ethnic minorities during adolescence many existing studies are based on regional data in england 7913 and some combine disparate ethnic groups into general classifications 7 broad categorizations such as south asian or black may mask important variations in overweight between subgroups 18 in addition there has been little exploration into the role of both socioeconomic and behavioural factors in uk ethnic minority adolescent obesity with only one previous londonbased study examining the contribution of behavioural risk factors within this age group 9 this study seeks to address these limitations by utilizing a large uk national dataset with ethnic minority representation in disaggregated groups we explore ethnic differences in midadolescence overweight as measured by bmi whilst also assessing the contribution of selected socioeconomic and behavioural factors methods the millennium cohort study is a uk representative longitudinal study the initial sample included 19 000 uk born children between 2000 and 2002 and data have been collected from participants at 7 points in time crosssectional interview data from the mcs at sweep 6 in 2015 were used in this study with the addition of birthweight data from earlier sweeps in 2001 and 2004 the majority of cohort members was aged 14 years at the time of the outcome data collection supplementary figure s1 shows the sample sizes for each survey sweep from ages 3 to 14 years reduced sample sizes across the survey sweeps have been attributed to several reasons including untraced moves emigration and refusals nonresponse survey weights were constructed for mcs6 to account for survey attrition 19 the study employed a twostage stratified clustered random sampling strategy with oversampling in disadvantaged wards and in areas with more than 30 asian or black residents data on cohort members and parents are collected at each sweep via interviews and selfcompletion questionnaires ethical approval for mcs6 was granted from the national research ethics committee london 20 body mass index anthropometric data from cohort members were collected by trained interviewers prior to measurement participants removed shoes socks outdoor clothing and hairstylesaccessories that could affect accuracy height was recorded to the nearest millimetre using a leicester height measure stadiometer with the measurement arm parallel to the frankfurt plane 21 weight was recorded using tanita tm scales to the 01 kg measurements were only repeated if the interviewer was not happy with the initial measurement any possible factors that could have affected measurement accuracy were recorded by the interviewer 21 bmi was derived from height and weight measurements and used as a continuous variable we also used the mcs derived overweight variable that is based on international obesity task force bmi age and sex specific cutoff points 22 overweight and obesity categories were combined into a single overweight category within a binary variable ethnicity ethnic classification was derived from the cohort member questionnaire where participants selfidentified their ethnicity from predefined categories we used eight categories in this analysis white mixed indian pakistani bangladeshi black caribbean black african and other ethnic group white ethnicity was the reference category in regression analyses covariates covariates were selected a priori based on previous evidence for associations with both overweight and ethnicity sep was measured via parental education and family income parental education represents the highest qualification obtained by main parental respondents over all mcs sweeps 94 of respondents were mothers consequently this variable reflects maternal education the variable was categorized into six categories no formal qualifications overseas qualification gcse below grade c gcse grade ac aas level and postgraduate degree or degree family income was categorized into equivalized income quintiles ordered from highest earning to lowest birth weight in kilograms was used as a continuous variable for all regression analyses for descriptive purposes birth weight was grouped into three categories based on office for national statistics classifications 23 dietary and behavioural factors consumption of breakfast fruit vegetables sugarsweetened beverages fastfood and physical activity were selfreported by cohort members and were all categorical variables a combined category of less than once a month hardly ever or never was used for ssb due to small numbers in some categories physical activity was recategorized as 5 days or more 34 days 12 days or not at all for similar reasons data analyses all analyses were performed using stata version 15 24 and mcs6 uk wide cross sectional survey weights to account for sample attrition across sweeps and the stratification and geographical clustering of the sample statistical significance was predetermined as p ¼ 005 the initial sample included 11 884 participants twins and triplets were excluded due to the associations between multiple births and low birth weight and possible impact on childhood overweight 25 nine observations with missing data for the income variable also had missing values for the survey characteristics and were removed finally 1217 observations were removed due to missing data for any covariate for complete case analysis giving a final sample size of 10 500 comparisons were made between characteristics of participants with any missing data and those with complete data in total participants with missing data amounted to just over 10 of the original sample size there were no significant differences between both groups in terms of the outcome variables birth weight or sex however the missing data group had a significantly higher proportion of ethnic minorities older participants and those from disadvantaged households those with missing data were also more likely to never consume breakfast or vegetables and to never participate in at least one hour of moderate physical activity within a week multiple linear regression was used to model the relationships between ethnicity and bmi logistic regression models were generated for the binary overweight variable as the outcome and ethnicity as the explanatory variable regression results were stratified by sex due to a significant interaction term for the bmi outcome for both outcomes a series of regression models was estimated model a was the baseline model estimating the association between ethnicity and overweightbmi adjusted for age model b additionally adjusted for sep markers model c additionally adjusted for birth weight and physical activity model d fully adjusted for all variables including dietary variables results table 1 shows descriptive statistics with weighted proportions and means 2102 cohort members belonged to an ethnic minority group of which pakistani participants formed the majority all ethnic minority groups had higher proportions of overweight adolescents than the white group apart from the mixed and indian groups black caribbean adolescents had the highest proportion of overweight adolescents mean bmi the relationship between ethnicity and overweight differed according to sex most notably in ethnic minority groups black caribbean males had an overweight prevalence of 533 whilst black caribbean females had a lower prevalence of 277 in contrast black african females had a prevalence of 515 whilst black african males had a lower prevalence of 262 indian males had a higher overweight prevalence than indian females there were also variations in the proportions of ethnic minority participants within the covariates larger proportions of ethnic minority groups were represented within the lowest income quintile containing more than two thirds of pakistani and bangladeshi adolescents in comparison to white adolescents low birth weight was more prevalent among most ethnic minority groups dietary and physical activity behaviours considered to be associated with overweight were all more prevalent in ethnic minority groups table 2 displays logistic regression models estimating the odds of being overweight for males unadjusted odds of overweight were significantly higher for both pakistani and black caribbean adolescents in comparison to white adolescents when adjusted for sep pakistani males no longer had significantly higher odds of overweight in comparison to white males adjusting for sep birthweight and physical activity reduced the odds of overweight for black caribbean males although the difference in comparison to white males was not fully explained even after full adjustment in females both pakistani and black african adolescents had significantly higher unadjusted odds of overweight in comparison to white adolescents after accounting for sep the difference between pakistani and white females was no longer statistically significant but black african females continued to display significantly higher odds of overweight in all models table 3 displays regression models predicting bmi in the baseline model black caribbean males had a significantly higher bmi compared with white males this difference remained statistically significant in all models although the estimate was slightly attenuated following adjustment for family sep markers the addition of birth weight and physical activity had little effect black african females had a significantly higher bmi than white females whilst indian females had a significantly lower bmi than white females before adjustments accounting for family sep markers resulted in attenuation of both estimates which remained significant adding birth weight physical activity and dietary variables to the model further attenuated the association among indian females but not among black african females discussion our findings show inequalities in bmi and overweight prevalence during midadolescence between uk ethnic groups within this sample ethnic differences in overweight patterns varied according to sex in comparison with their white counterparts black caribbean males had higher odds of overweight whilst black african females had higher odds of overweight indian females were the only ethnic group to have significantly lower bmi than white females ethnic differences in childhood overweight between males and females have previously been identified in research with values displayed are coefficient estimates model a crude association between ethnicity and bmi age model b model a additional adjustment for maternal education family income model c model b additional adjustment for birth weight physical activity model d fully adjustedmodel c additional adjustment for dietary variables a white ethnicity is the reference group ethnic variations in overweight prevalence 403 of 405 higher prevalence often reported in black females as seen in these data 7926 reporting bmi prevalence in disaggregated ethnic groups has revealed some distinctions such as the contrast in levels of overweight between black caribbean and black african adolescents and between indian and pakistanibangladeshi adolescents these ethnic groups are often analyzed together as in some previous adolescent studies 7 thus masking such inequalities a similar but slightly smaller study also assessed overweight prevalence in disaggregated ethnic groups and found both black caribbean and black african females had higher prevalence of overweight in comparison to white females 9 however this study 9 also found that other males had higher prevalence of overweight in comparison to white males which contrasts with our findings such distinctions may be relevant information for targeted obesity interventions but larger scale studies with higher representation of these disaggregated adolescent ethnic groups are needed to verify the findings of this research there were clear stepwise social gradients in bmi by family income for both sexes but no similar gradients were observed by maternal education sep explained part of the association between ethnicity and bmi except for indian males it appears that the high prevalence of deprivation in pakistani and bangladeshi groups is a major factor for these inequalities in bmi prevalence in the previous research the role of sep in explaining ethnic differences in overweight and obesity has been inconsistent some previous smaller scale studies involving adolescent ethnic groups in england did not find significant associations between sep and bmi in samples including adolescent ethnic groups 2627 however in line with our findings a previous mcs study in younger children also found sep adjustments attenuated increased overweight prevalence in 5yearold bangladeshi children to nonsignificant levels 28 in the current study sep adjustments did not ultimately explain all ethnic group variation in overweight and bmi with higher levels remaining particularly among black compared with white groups furthermore recent research has found that the association between sep and overweight is reversed in some uk ethnic groups with children from lower income black african and black caribbean groups having a lower risk of overweight than higher income families from the same ethnic group 29 although high birth weight frequent physical activity and frequent breakfast consumption were associated with lower bmi these factors did not play a substantial role in explaining differences in bmi between ethnic groups a previous study examining the role of dietary factors in adolescent obesity found poor dietary behaviours including skipping breakfast more prevalent in black african females alongside high levels of overweight 9 in this study unhealthy behaviours did not explain the patterns of obesity prevalence observed vegetable consumption was not associated with bmi in any model and the frequent consumption of ssb was only associated with higher odds of overweight in males contrary to expectations both lower fruit consumption and higher fastfood consumption were associated with lower bmi this may be due to reporting bias with the possibility that adolescents who were overweight reported less frequent fastfood consumption and higher fruit consumption in line with wellknown general health messages regarding obesity the reverse association in fastfood consumption has been reported previously in international studies on adolescents 30 limitations although oversampled there were low numbers for some ethnic minority groups within the sample with implications for statistical power the findings regarding higher levels of overweightbmi in black caribbean males and black african females are statistically significant but the associated 95 confidence intervals are large due to small numbers in each group additionally a growing body of evidence highlights the limitations of bmi to account for variant body compositions in children from different ethnic groups 3132 bmi does not account for lean body mass and may have the propensity to underestimate body fat in south asian groups and overestimate body fat in black groups 31 this may have implications for the validity of the estimated overweight levels in these analyses unfortunately there are no current validated ethnic specific adjustments for children over the age of 12 years that could be applied to our data the crude nature of the dietary questions included in mcs did not allow for an assessment of total energy consumption and may not accurately reflect dietary patterns it may well be easier to recall if breakfast was consumed or not than the exact frequency of fruit and vegetable consumption over a day furthermore portion sizes were not accounted for in the ssb or fastfood questions and it is not clear whether other dietary practices not measured by these variables may play a more significant role in explaining overweightbmi differences consequently these findings should be interpreted with caution research and policy implications the most recent census data from england and wales revealed that 14 of the population belonged to an ethnic minority group 33 this is projected to increase to 25 of the population by 2051 34 in light of the anticipated uk ethnic population expansion and increased childhood excess weight prevalence within some ethnic groups it is important to identify highrisk groups accurately to inform obesity reduction strategies moreover further research is needed to examine other possible contributory factors not examined here such as cultural or gender differences in body image 16 these may help to explain the higher prevalence of overweight in south asian and black ethnic adolescent groups particularly black african females who consistently show higher prevalence in research conclusions this research adds to the limited evidence base regarding overweight prevalence within uk ethnic groups during midadolescence it highlights further the complexities around identifying significant contributory factors to excess weight prevalence in minority groups further detailed research is required to investigate possible explanatory factors for higher overweight prevalence in ethnic minority adolescents in order for effective intervention strategies to tackle adolescent overweight supplementary data supplementary data are available at eurpub online

background there are stark ethnic inequalities in the prevalence of uk childhood obesity however data on adolescent overweight in different ethnic groups are limited this study assessed ethnic inequalities in overweight prevalence during midadolescence using body mass index bmi and explored the contribution of socioeconomic and behavioural factors methods we analyzed data from 10 500 adolescents aged between 13 and 15 years who participated in sweep six of the millennium cohort study ethnic inequalities in overweight and mean bmi were assessed using multiple regression models results were stratified by sex and adjusted for socioeconomic and behavioural factors results black caribbean males had significantly higher bmi than white males after full adjustment excess bmi 294 95 confidence interval ci 070519 and were over three times more likely to be overweight odds ratio or 332 95 ci 195566 black africans females had significantly higher bmi compared with white females excess bmi 186 95 ci 089283 or for overweight 274 95 ci 164456 while indian females had significantly lower bmi compared with white females reduced bmi à073 95 ci à137 to à009 socioeconomic and behavioural factors often considered to be associated with overweight were more prevalent in some ethnic minority groups lower socioeconomic position lack of breakfast consumption low fruit and vegetable intake high sugarsweetened beverage and fastfood consumption and infrequent physical activity but adjustment for these factors did not fully explain ethnic differences in overweightbmi conclusion ethnic inequalities in overweight prevalence are evident in midadolescence and vary according to sex differences in overweightbmi between ethnic groups were not fully accounted for by socioeconomic or behavioural factors

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feelings of anxiety and fear are common among women who become pregnant again following a pregnancy loss women report constant reminders of the loss during a subsequent pregnancy such as continuously comparing pregnancy symptoms as a way to reassure themselves that the current pregnancy is still viable postpartum depression is more common among new mothers who experienced a prior loss with some women reporting symptoms of posttraumatic stress despite the negative emotions that often accompany a subsequent pregnancy following a loss the majority of women who experience a loss become pregnant again with many pregnancies occurring less than a year after the loss although research has largely focused on negative emotions and psychological wellbeing after a pregnancy loss there is evidence that becoming pregnant after a pregnancy loss is associated with feelings of hope and optimism that the subsequent pregnancy will result in a live baby and a higher importance of motherhood we know less however about how women feel about a subsequent pregnancy that ends in live birth published research tends to focus on longterm adverse effects of pregnancy loss such as problems with fostering secure attachment relationships with subsequent children and lingering depression and anxiety in this study we utilize national data to examine if women felt more or less happy about a pregnancy occurring after a pregnancy loss compared to pregnancies that do not occur after a pregnancy loss happiness is a positive indicator of maternal wellbeing related to a pregnancy that follows a pregnancy loss we also consider how the intendedness of the pregnancy interacts with a prior loss to impact happiness literature review childbirth after pregnancy loss pregnancy loss is a relatively common experience among women of childbearing age approximately 1420 of all pregnancies in the united states result in miscarriage or a loss during the first twenty weeks of pregnancy and another 05 result in stillbirth a loss after the twentieth week women experience a variety of psychologically distressing outcomes following miscarriage including grief anxiety depression stress and guilt often these adverse outcomes are sustained over time pregnancy loss can be particularly distressing when it occurs along with other reproductive events such as infertility other pregnancy losses and whether the pregnancy was intended happiness about pregnancy following a loss studies on happiness situate the concept within the subjective wellbeing framework as opposed to negative affect and psychological disorders swb includes life satisfaction positive and negative experiences happiness and life satisfaction are frequently used interchangeably especially when measurement reflects evaluation of ones life across multiple domains swb studies also examine happiness related to specific domains studies on swb that are domain specific frequently focus on mental physical economic and social domains but studies of perinatal positive indicators of wellbeing remain scarce allan et al state that perinatal wellbeing includes physical psychological social spiritual economical and ecological dimensions for pregnant women the emotional psychological and physiological changes experienced during pregnancy uniquely influences their evaluation of these domains in the us happiness is frequently associated with positive feelings individually experienced as something to achieve pregnancy is both a developmental process and a social event where a healthy pregnancy and child is the goal cultural narratives valorizing motherhood complicate the pregnancy experience for many women during pregnancy and indeed even prior to getting pregnant women experience considerable internal and social pressure to sacrifice for their baby women report feeling internal and external pressure to have a perfect pregnancy and experience distress when they do not always feel the positive emotions associated with pregnancy adverse events during pregnancy and perinatal loss or stillbirth induce feelings of guilt and anxiety during subsequent pregnancies prior pregnancy losses therefore may complicate feelings of happiness and ability to feel joy during a subsequent pregnancy the public health impact of unintended pregnancy is considerable women who carry an unintended pregnancy to term are more likely to delay prenatal care use alcohol and tobacco and experience low infant birth weight preterm birth and maternal morbidity and mortality although pregnancy intentions are important to assess because of their implications for healthy pregnancies and child outcomes pregnancy happiness is also an important indicator of pregnancy desirability with implications for other outcomes happiness about a pregnancy even if it is unintended is associated with lower psychosocial and biological stress happiness about a pregnancy may also have important implications for future maternal and child health women who reported higher levels of happiness when they found out they were pregnant for example are more likely to breastfeed and less likely to use substances during pregnancy despite this evidence that pregnancy happiness has implications for understanding maternal behaviors health and wellbeing previous research on pregnancy happiness has focused primarily on disentangling it from pregnancy intentions rather than on predictors of pregnancy happiness per se unsurprisingly pregnancy intentions are strongly though not entirely correlated with happiness examining the influence of trying to get pregnant on levels of happiness may provide insight to the meaning of terms across different groups of women for example hartnett found that hispanic women reported being happier about unintended pregnancies compared to white and black women particularly among foreignborn hispanics a history of pregnancy loss may further complicate the association between trying to get pregnant and happiness about the pregnancy the limited studies on maternal happiness and the lack of research that simultaneously assesses pregnancy intentions prior pregnancy loss and happiness about a pregnancy raises the following questions do women who experienced a prior pregnancy loss have the same feelings of happiness about a pregnancy as women who did not experience a prior loss does this association differ depending upon whether or not the women were trying to conceive data and methods sample the national survey of family growth a multistage area probability design survey provides most of the national estimates related to fertility since 1965 the target population for the nsfg is men and women between the ages of 1445 years old in the united states we combined cases from cycle 6 2002 we combined the data files for a total of 25523 observations we restricted the analytical sample to women with at least a one pregnancy and at least one birth reducing the sample size to 14237 to examine the association between prior pregnancy loss and a subsequent birth we use births as the unit of analysis we merged the pregnancy file data for years 20022013 with the respondent file and restricted the analytical sample to pregnancies that ended in a live birth resulting in 30110 observations the outcome variable happiness about a specific pregnancy was only asked of births occurring within 3 years of the interview date restricting the sample to 6668 births finally we used listwise deletion to select only cases with no missing values on the focal variables resulting in 6640 observations for the analytic sample the nsfg oversampled by age sex and race if more than one eligible respondent lived in the sampled household screeners used a computer program to select one sampled respondent per household the nsfg includes base weights poststratified adjusted weights and population weights because the nsfg employed a multistage stratified sample design with clustering we use the surveyprovided weights strata and clustering variables furthermore we followed kost and lindbergs strategy of using the respondents identification number as a clustering variable to account for multiple birth observations by the same mother concepts measures for happiness about pregnancy respondents were asked on this scale a 1 means that you were very unhappy to be pregnant and a ten means that you were very happy to be pregnant because there was considerable clustering of responses in a few categories we followed hartnetts approach and recoded the scale into a binary construct with 6 to 10 coded as 1 for happy and 1 to 5 were coded as 0 for not happy sensitivity analyses comparing results using the dichotomous measure with the original ordinal scale measure did not have substantively different results we measure pregnancy intentionality with the conventional nsfg constructed measure with 6 categories lateroverdue right time too soon didnt care unwanted dont know most researchers combine the later overdue right time dont know and didnt care categories into one group we collapsed the lateroverdue and right time categories together into ontime and combined dont know and didnt care into a separate ambivalence category because women with a history of prior pregnancy loss may have more ambivalent desires for a pregnancy the resulting pregnancy intention measure has four categories ontime mistimed unwanted and ambivalent the next set of variables includes pregnancy loss and behaviors we created prior pregnancy from a survey constructed variable indicating pregnancy order of the conception nsfg also constructed a birth order variable for every birth we created a dichotomous variable indicating if the difference between pregnancy order and birth order was greater than zero that is for each specific birth if the difference between pregnancy order and birth order was greater than one the respondent experienced a pregnancy loss prior to that birth we also control for birth order in the regression models using a threecategory measure including first birth second birth and 3 or higher birth order the measures of first birth context include age union status and medical insurance status at first birth we measure age in years we used the constructed variable for relationship union status at the time of birth and collapsed the responses into the following categories separated divorced and widowed compared to married cohabiting and single because the united states did not have universal health insurance during the study time period health insurance is an important proxy for access to affordable medical care we included a dichotomous variable indicating whether the delivery of the specific birth was paid for by medicaid social class was measured by the respondents years of completed education at the time of interview we also include raceethnicity nativity status and religion as additional potentially relevant background variables to reduce the risk of disclosure the publicly available nsfg datasets only include recoded variables collapsing groups for both raceethnicity and religion we used the publicly available categories to create dummy variables to use in analyses the raceethnicity variable includes four dummy variables white hispanic black and other religion was also coded into four dummy variables none catholic protestant and other results table 1 shows the weighted descriptive statistics for births and respondent characteristics by prior pregnancy loss status as well as for the full sample about 67 of births occurred after no pregnancy loss 22 occurred after one pregnancy loss and 11 after two or more losses roughly 80 of the sample reported being happy about their pregnancies and the reported level of happiness varied by prior pregnancy loss with women who experienced one loss reporting higher levels of happiness at the time of pregnancy discovery followed by women with no losses and lastly women with two or more losses there is a bivariate association of the prior pregnancy loss status of births and birth order a higher percentage of births occurring to women with no history of loss were first births than births occurring to women with a history of one loss or two losses births occurring to women with two or more losses were more likely to be 3 rd or higher order births compared to the percentage of 3 rd or higher births to women with no prior pregnancy losses or one prior pregnancy loss there is also an association of the intentions status of births and prior pregnancy loss status a higher percentage of births occurring to women who had no prior pregnancy loss were reported as mistimed than those with one or two or more prior losses the smallest proportion of unwanted births occurred to women with one prior pregnancy loss and the highest proportion to women with two or more prior pregnancy losses the average maternal age at birth was highest for births to women with two or more pregnancy losses followed by one prior loss and no prior losses the characteristics of mothersmarital status at time of birth medicaid education and raceethnicity did not differ by pregnancy loss status multivariate results table 2 shows the odds ratios coefficients and standard errors estimated from three logistic regression models of happiness about a pregnancy the first model included prior pregnancy loss birth order birth context and sociodemographic characteristics of the mother model 2 added pregnancy intentions to the model model 3 adds interactions of pregnancy loss with pregnancy intention and loss with birth order in the first model one prior pregnancy loss was associated with significantly higher odds of being happy about a pregnancy as anticipated relative to first births mothers with one child or two or more children had significantly lower odds of reporting being happy about their pregnancy each year older is associated with higher odds of happiness about a birth compared to births to married women the odds that women who were cohabiting divorcedseparatedwidowed or single report being happy about a conception were significantly lower the odds that women report being happy about conceptions resulting in a birth is higher for women who are hispanic and catholic in model 2 we added the pregnancy intentions variable as anticipated from prior research women were significantly less likely to report being happy about a pregnancy if it was mistimed unwanted or if they were ambivalent compared to reports about births that were ontime controlling for pregnancy intention status also changed the coefficients for prior pregnancy loss in model 2 if the pregnancy occurred after one prior pregnancy loss the odds ratio is smaller and not significant and the odds ratio for two or more prior pregnancy losses is associated with a larger odds ratio that is now statistically significant a few other indicator variables are no longer statistically significant controlling for pregnancy intention status the last model includes the interaction terms for prior pregnancy loss with pregnancy intention and prior pregnancy loss with birth order because the meaning of the coefficients for the interaction terms comes from combining several coefficients we facilitate interpretation with graphs of the predicted probabilities of pregnancy happiness in figures 1 and2 the figures show that intention status moderates the association of pregnancy loss and happiness about a subsequent pregnancy that resulted in birth but only for those whose intentions for conception were ambivalent and had two or more losses figure 1 shows that births occurring to women without a history of loss who were also ambivalent about a subsequent birth were over four times as likely to be happy about their pregnancy compared to women who were ambivalent and had a history of two or more prior pregnancy loss the results suggest that pregnancy loss and ambivalence have implications for happiness about pregnancy figure 2 provides a graph of the results for the interaction between prior pregnancy loss and birth order the coefficient indicating the association of the second birth with happiness about the pregnancy is for those with no prior pregnancy loss in model 3 because the interaction terms for one and two or more are in the model the main effect of second birth is not significant but the interaction terms for first or two or more pregnancy losses are significant there are substantially lower odds of reporting being happy about a pregnancy leading to a second birth if the birth follows a pregnancy loss in contrast the main effect for the third or higher births is significant and indicates that women have lower odds of reporting happiness about a third birth pregnancy loss does not modify the association between 3 rd and higher order births and happiness in this study we asked do women who experienced a prior pregnancy loss have the same feelings of happiness about their pregnancies as women who did not experience a prior loss does prior pregnancy loss modify the association of pregnancy intention and birth order with happiness about pregnancy the answer to the first question is yes there is a direct association of prior pregnancy loss with happiness about pregnancy women with one prior loss had the highest happiness and women with two or more pregnancy losses had the lowest happiness the answer to the second question is that there is a modest and partial interaction of pregnancy intention with prior pregnancy loss and birth order discussion this study contributes to the body of literature on pregnancy loss pregnancy intentions and happiness in three ways first the odds of reporting happiness about pregnancies resulting in a birth is higher for women with a prior pregnancy loss compared to those with no pregnancy loss therefore reproductive events do not occur isolated from other experiences indeed the first pregnancy and its outcome continue to influence how women feel about subsequent pregnancies and births although many women with a history of pregnancy loss experience negative emotions in subsequent pregnancies having one prior pregnancy loss is associated with higher odds of being happy about a birth second we examined the influence of intendedness of a subsequent pregnancy on happiness although many women conceive again following a pregnancy loss most of the extant research is on the experience of a subsequent pregnancy rather than the intendedness couples with a history of loss may be more likely to try again as soon as possible after a loss however data to assess this research question are limited alternatively the feeling of uncertainty many women experience after a pregnancy loss may make them less likely to want to actually try for another pregnancy very few studies utilizing nsfg data include the ambivalent category of pregnancy intentions in part because of small sample sizes in each cycle who reported ambivalence towards a particular pregnancy pooling multiple years and cycles of nsfg data provided us with enough cases to make meaningful comparisons we did not find that prior pregnancy loss on its own resulted in lower odds of being happy about a later pregnancy but for women with a history of loss having ambivalent intentions about a subsequent pregnancy was associated with a significantly lower probability of being happy about that pregnancy it could be that these are the women who have difficulty with attachment following pregnancy loss women who experience greater distress about prior pregnancy losses may be reluctant to prevent a pregnancy but then are less able to feel attachment to their babies who survive future research should consider whether or not women with multiple losses are less likely to plan a future pregnancy because of low selfefficacy or a low sense of power to control the outcome of a pregnancy women with multiple losses may benefit from targeted counseling to determine readiness for a subsequent pregnancy making a conscious and informed decision to try and get pregnant again may give women a sense of control yet it could also give false hope given the association between pregnancy intention and maternal health during pregnancy future research should also explore if women with a history of loss and ambivalence are more likely to experience pregnancy complications and engage in riskier behaviors we also considered the birth order of each specific pregnancy for happiness about pregnancy a conception leading to the second birth is not significantly associated with lower levels of happiness about a conception except for women with a history of pregnancy loss we did not find significant differences for first births or birth orders of three or higher limitations the strength of the current study is the new insights provided about the connections between prior pregnancy loss intentions and happiness about a subsequent pregnancy all studies however have limitations the current analysis did not include an indicator of the type of pregnancy loss experienced and induced abortions are often underreported therefore differences in happiness about pregnancies that do or do not occur after a prior pregnancy loss may be larger than presented here because some women who had abortions could be in the no loss category the approach we took in this paper was not to separate out pregnancy losses that occurred by stillbirth spontaneous or induced abortion rather we approached loss as a broad measure of reportable prior pregnancies that did not result in a live birth one of the challenges associated with examining specific types of pregnancy loss is the complication related to multiple outcomes of multiple pregnancies in many instances women might experience both miscarriage and induced abortions but small cell sizes prevent an analysis of the women in separate groups furthermore the sequence and order of the type of pregnancy loss is quite complicated to parse out and beyond the scope of this paper future research should consider using a sequence analysis of pregnancy outcomes as a way to summarise complex pregnancy histories pregnancy intendedness remains a difficult concept to measure in part because the meaning of ambivalence is unclear ambivalence could reflect an orientation toward pregnancy viewing it as something that cannot be controlled or as something that should not be controlled for at least some women who reported ambivalent intentions particularly those with a history of prior pregnancy loss pregnancy might be viewed as something that happens to them rather than something that they decided to engage in ideally reports of pregnancy intentions would precede births but in the nsfg pregnancy intentions are retrospective reports there is evidence that over time women report different levels of intending for the same birth longitudinal data would provide more confidence in timing and recall of pregnancy intentions for each birth there is no theoretical or prior research finding to explain why prior pregnancy loss has different associations with pregnancy happiness based upon birth order one reason why second births are associated with lower happiness after a prior pregnancy loss could be that for women who had at least one live birth but experienced a loss before or after that birth there is a reluctance to feel happy about a subsequent pregnancy because of lack of trust that the child will be okay women with at least two live births may feel more confident about their ability to have a third child because they know their bodies can sustain a pregnancy yet as with many studies the results raise new questions there is a need for future research to explore patterns of losses by loss type and sequence across pregnancies and births there is a need to establish patterns of reproductive sequences and happiness about a pregnancy finally it is possible that future datasets will keep the rich pregnancy history feature of nsfg and include multiple indicators of psychological states such as depression or anxiety unfortunately the present study is limited to the happiness measure available in the nsfg conclusion we anticipated that the context of experiencing a pregnancy loss would be associated with a lower level of happiness with a subsequent birth but did not find that to be the case instead happiness about pregnancy is virtually the same across births regardless of whether or not women experienced a prior pregnancy loss we did find however that that pregnancy loss modifies the association of pregnancy intention with pregnancy happiness women who experienced two or more pregnancy losses and had ambivalent intentions about a subsequent pregnancy were less likely to report being happy about that pregnancy compared to those who intended and did not have a prior loss shreffler et al found that women who think of themselves as infertile or subfertile are more likely to report ambivalent pregnancy intentions thus it might be that a pregnancy loss heightens concerns about fecundity and therefore reduces happiness about a subsequent pregnancy because other studies found associations between happiness and maternal health clinicians may be able to offer targeted treatment and advice by asking women with a history of pregnancy loss about both intentions and happiness about a pregnancy for women with a history of pregnancy loss discussions with their doctors about conflicting emotions and fears may reassure women and potentially reduce experiencing guilt for feeling anything other than happiness about their pregnancy prior pregnancy loss status also modified the association of birth order and happiness about a pregnancy as described above women with second births who had prior pregnancy losses had substantially lower predicted probability of happiness about the pregnancy compared to women who did not have a prior loss or birth we conclude that the prevailing impression of lingering negative effects of prior pregnancy loss on the experience of subsequent childbearing is not necessarily the case and is complicated by pregnancy intentions and birth order the overall pattern from nationally representative data is that most women are happy about their pregnancies regardless of whether or not they follow a pregnancy loss disclosure no potential conflict of interest was reported by the authors

objective this study aimed to examine the interaction between pregnancy loss and pregnancy intentions on womens happiness about a subsequent pregnancy background anxiety about prior loss persist for women even during subsequent pregnancies it is unclear from prior research whether a prior pregnancy loss shapes attitudes towards and feelings about a subsequent birth methods using data from the 20022013 national survey of family growth nsfg we used logistic regression analyses to explore the implications of a prior pregnancy loss for happiness about a subsequent pregnancy that ends in a live birth we compared births classified as ontime mistimed unwanted and ambivalent results births were more likely to be characterized as ontime if they occurred following a pregnancy loss and women were less likely to report being happy about a conception if they were ambivalent about the conception and experienced a previous loss overall pregnancy loss alone was not associated with lower levels of happiness about a subsequent birth

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data source the ndhs is a nationally representative health survey conducted every 5 years using a multistage sampling procedure standardized tools and welltrained interviewers 8 it is the worlds largest survey eliciting information on infant and child mortality rates and demographic factors generated from birth histories obtained from the mothers interviewed 2 the dhs also contains information on socioeconomic and geographic characteristics including household ownership of assets maternal education and ruralurban residence 426 as measuring inequalities in childhood mortality requires information on age at death of underfive and socioeconomic status the 2018 ndhs birth recode data file was used it contained 127545 sample sizes with a response rate of 99 8 analysis in this study was restricted to children aged 059 months variables the dependent variable is descriptive binary plus time in months until the event occurs in line with previous studies 1921252728 the independent variables comprise child gender mothers age household wealth index maternal and paternal education ethnic origin religion place of residence and geopolitical zone table 1 presents the description of variables used in the analysis statistical analysis we used a survival analysis method to examine survival timetoevent data of the three survival analysis techniques we adopted the later for analysing censored data 21 and for it capacity of letting the dataset speak for itself 29 we used the two most common nonparametric methods in survival analysis viz kaplanmeier survival estimates and logrank test statistic to assess the survival function and pattern of underfive mortality 20 30 31 32 the kaplanmeier survival estimates were used to present graphically a survival curve that plots survival probability against time 20 the conditional probability of a childs survival increases as heshe progresses in age 33 kaplanmeier provides a useful summary of the data that can be used to estimate measures such as median survival time 34 survival data are modelled in terms of two related functions the survivor function and the hazard function 34 assume t to be a random variable representing the survival time of subjects in the population and t be the realization of t the cumulative distribution function of t is expressed as f p where t denotes the actual survival time of a child t indicates a random variable associated with the survival time and f is the probability density function for the survival time the distribution function of t and survival function s show the proportion of children that survive longer than t from the first day of birth and is expressed as the hazard function h represents the probability that an individual dies at a time conditional on having survived to that time that is the function represents the instantaneous death rate for an individual surviving to time t where h is the hazard function t is the survival times is the survival function and is the instantaneous change 1921 the cox proportional hazards regression model the most widely used model in the analysis of survival data was used to assess the influence of various covariates in the survival times of individuals through the hazard function 19 it provides a hazard ratio to compare survival times of two or more population groups the observation is rightcensored that is the survival status of the individual might not be known at the time of the survey 1925 in the model the exponentiated linear regression portion of the model explains the effects of explanatory variables on hazard ratio 19 the cox hazard is modelled as follows where x 1 to x k are k explanatory variables and h 0 is the baseline hazard at time t representing the hazard for a person with the value 0 for all the explanatory variables by dividing both sides of eq by h 0 and taking logarithms we obtain where h h 0 is the hazard ratio the coefficients b 1 to b k are estimated by the cox regression 25 three models were fitted into the cox proportional hazards model for analysis to investigate the influence of the predictor variables on the underfive mortality model 1 contained demographic factors as the only predictor variables while model 2 added socioeconomic variables model 3 included environmental and geopolitical variables along with the previous variables in models 1 and 2 for analysis 21 in the cox proportional hazards model the outcome is described in terms of the hazard ratio the cox regression model gives the hazard function as a product of a baseline hazard involving t and an exponential expression involving x ′ s without t the exponential part of the equation ensures that the fitted model will always give estimated hazards that are nonnegative 35 the hazard ratio represents the instantaneous risk over the study time the measures of association were expressed as hazard ratios with 95 confidence intervals 20 a hazard ratio of 1 means lack of association a hazard ratio 1 suggests an increased risk and a hazard ratio 1 suggests a smaller risk in general the survivor function focuses on not having an event while the hazard function focuses on the event occurring 34 all analyses were weighted to ensure representativeness of the survey sample a pvalue less than 005 is considered statistically significant we conducted all the analysis using stata version 131 more so all methods were performed in accordance with the relevant guidelines and regulations ethical approval and consent to participate the demographic and health surveys program has granted approval to use the nigeria dhs dataset for this study the dhs adhered to informed consent and we observed anonymity and confidentiality under the data terms of use results table 2 presents the descriptive statistics of variables used in the study and distribution of underfive deaths across the demographic geographic and socioeconomic characteristics the results show that the proportion of underfive mortality is about 10 and higher among the male than the female gender although the proportion of age of child is highest among the childhood group the proportion from total u5m is the highest among the neonatal age bracket further the result indicates that the proportion of u5m is prevalent among children born to mothers age ≤ 19 at first birth especially among the hausafulanikanuri ethnic origin and the muslim groups moreover the socioeconomic variables show that the u5m was higher among children born to mother and father with no formal education compared to the children born to mother or father with primary secondary or tertiary education in the same vein of the household wealth index quintiles 654 of the underfive death occurred among the three lowest wealth quintiles poorest poorer and middle about 614 of the u5m occurred in rural areas while the remaining 386 occurred in urban areas in nigeria of the six geopolitical zones 683 of u5m occur in the three northern geopolitical zones north west north east and north central compared to their southern counterparts the majority of u5m occurs among those residing in rural areas f p t 0 f du s p 1 f h lim �→0 p s h h 0 exp ln h h 0 b 1 x 1 b 2 x 2 b 3 x 3 • • • b k x k figure 1 presents proportion of underfive death by geopolitical zones in a nigeria map of the six geopolitical zones north west followed by the north east and north central had the highest underfive death compared to the south east south west and south south figure 2 shows the kaplanmeier estimates of the survival graph for all the underfive children the horizontal axis indicates the time to event in months while the vertical axis shows the survival probability or the proportion of underfive children surviving at time 0 the survival probability is 100 thus the result indicates most underfive death occurs at earlier months after birth figure 3 graphically presents kaplanmeier survival estimates of underfive mortality by household wealth index quintiles the graph shows that the top wealth quintiles had higher underfive survival probability than the bottom quintiles the survival probability is high for the richest but relatively low for the poorest even so the survival probability of the poorer and the poorest were almost the same the statistically significant value of the logrank test for equality of survivor functions for household wealth index indicates differences in survival probability among different socioeconomic groups figure 4 plots the kaplanmeier survival estimates of underfive mortality by geopolitical zones the graph indicates that the north west followed by the north east and the north central have the most at risk of survival among the six geopolitical zones while south south south east and south west have a lower risk of survival the geographic zones logrank test for equality of survivor functions is statistically significant table 3 presents the results of the cox proportional hazard regression analysis it assesses the influence of different factors on the survival time of underfive children the demographic variables included in model 1 assessed the independent influence of demographic factors on the risk of underfive deaths the result shows that u5m is 155 higher among male children than female children moreover u5m is 254 higher in children born to mothers age ≤ 19 at first birth than children born to mothers age 2039 at first birth further the results show that mortality by ethnic origin is 478 247 and 259 lower for children whose mothers are from the yoruba igbo and other ethnic origin respectively compared to the children whose mothers are of hausafulanikanuri origin more so the u5m is 262 higher among children born to muslim mothers than children born to christian mothers model 2 examines the influence of demographic and socioeconomic variables on the risk of underfive deaths results indicate that u5m is 152 higher for male children than females in addition u5m is 157 higher in children born to mothers aged ≤ 19 at first birth children of yoruba and other ethnic origins had 333 and 203 respectively lower u5m compared with the hausafulanikanuri ethnic origin about 220 u5m occurs among children of muslim mothers than children of christian mothers these findings show a significant association between u5m and paternal education results show that children born to fathers with no formal education primary education and secondary education had 328 252 and 180 respectively have a higher risk of u5m compared to children born to fathers with tertiary education of the household wealth index quintile the richest and richer groups had 361 and 196 respectively lower risk of u5m compared with the poorest quintile group finally the results of model 3 for demographic factors were consistent with models 1 and 2 results in the same vein results indicate that children born to fathers with no formal education primary education and secondary education had 360 279 and 204 respectively higher risk of u5m compared to children born to fathers with tertiary education moreover results suggest that the richest and richer wealth quintile groups had 297 and 135 respectively lower risk of u5m compared with the poorest quintile of all the geopolitical zones children born to mothers living in the north west had 634 higher risk of u5m than south west zone discussion evidently underfive mortality rate is the highest in subsaharan african countries and nigeria in particular notwithstanding that these deaths are preventable in part by addressing the associated demographic geographic and socioeconomic factors 18 this study investigates the geographic and socioeconomic survival differences of underfive in nigeria findings from the kaplanmeier survival estimates show the most u5ms occur within 12 months after birth with the poorest most at risk of u5m while the richest are the least affected across household wealth index quintiles the findings are in tandem with the unicef report that underfive deaths are increasingly concentrated in the neonatal period 536 besides our finding is in line with the assertion by lartey and colleagues that the probability of a childs survival increases as the child progresses in age and that the survival probability is lower for children from the poorest families but higher for the children from the richest families 33 therefore u5m reduction interventions may target children under 12 months of birth given their fragile immune systems this is to protect them from the perennial environmental threats to child health such as malaria lack of clean water and poor sanitation 217 further the finding shows that of the six geopolitical zones in nigeria the northern zones especially north west north east and north central are at the most risk of u5m earlier studies 62337 corroborate that the risk of underfive deaths is higher in the north west and north east regions owing to higher proportions of home delivery and complications during childbirth younger age at birth of first child and poor utilization of modern health facilities compared to the southern region the finding establishes that geopolitical setting strongly influence the health and survival chances of children 1 thus implying that u5m risks could be contained depending on the geopolitical environment children in which find themselves 16 as a corollary our study shows that children born to mothers living in rural areas experience higher u5m compared to their urban counterparts often children born to poor mothers in rural areas are delivered at home 38 this is not surprising as modern health care is not easily available in rural areas as in the urban area hence urban areas are reported to have lower u5ms than rural areas 61827 the cox proportional hazard regression models show that paternal education is negatively related to u5m increased paternal education leads to a reduction in u5m and vice versa this is in tandem with the assertion that parental education increases a childs survival probability 30 however contrary to expectations the maternal education was not statistically significant although mothers education has a relatively higher impact on child mortality than fathers education and many other socioeconomic factors 27333839 this could be due to the finding that mothers in northern nigeria have a higher proportion of no education or primary education 37 due to early 23 and combined with the fact that culturally husbands are the overall decisionmakers and breadwinner especially in the regions 40 moreover the cox regression model of the household wealth index shows that the rich had lower risk of u5m compared to the poor as shown in cox models 2 and 3 a study in india affirms that the risk of child mortality is the highest among the poor 41 it presupposes that a targeted intervention to the poor is necessary to close the gap this study also shows that children from hausafulanikanuri ethnic origin experience more underfive mortality compared to the southern region earlier studies in nigeria indicates that a child born in the north west has a 25 times higher probability of dying before age five than one born in the south east 42 this could be due to the preponderance of early marriage commonly practiced in northern nigeria thus given that education is a fundamental factor to consider in terms of child survival irrespective of region formal education sensitization particularly in northern nigeria would help alleviate childhood mortality in the country 6 the results consistently indicate that male children have higher mortality compared with female children this is supported by literature that males have a higher mortality in infancy in both nigeria and globally 43 it brings to fore the findings of wegbom and colleagues that u5m in nigeria is diversely affected by healthrelated factors and nonhealth sector factors such as demographic economic environmental social and security 21 therefore it requires a health equityinall policies approach to tackle underfive mortality 44 the strength of this work is the use of the kaplanmeier survival estimates and cox proportional hazard model for analysing timetoevent data and censored observations nevertheless this study is subject to some limitations firstly although dhs is a renowned reliable data source on child mortality 236 we acknowledge the inherent data collection challenges that could manifest through misreporting of age of child or age at death in months secondly our analyses focused on u5m over the last 5 years and the household wealth index constructed for the survey year was used as one of the proxies for socioeconomic status since changes in household wealth often occur in the longrun the current measures of wealth index can be a valid proxy for past values 45 notwithstanding this the current measure of both dependent and independent variables would have been ideal for the analysis lastly as our analyses were based on retrospective crosssectional data temporality could not be established between explanatory variables and geographic or socioeconomic inequality in u5m thus impeding causal inference conclusion achieving a reduction in u5m is a public health concern that requires a multidimensional approach there is a need to tailor u5m reduction interventions to the critical survival time of 12 months after birth a target intervention in geopolitical zones especially the north west north east and north central will be of utmost importance to increase access to needed health care services in addition increased formal education particularly in northern nigeria is vital for u5m reduction in the country given that education is a fundamental factor to consider in terms of child survival irrespective of region data availability data for this study is publicly accessible upon request from the dhs website dhspr ogram com data avail abledatas ets cfm competing interests the authors declare no competing interests

despite a substantial decline in child mortality globally the high rate of underfive mortality in nigeria is still one of the main public health concerns this study investigates inequalities in geographic and socioeconomic factors influencing survival time of children underfive in nigeria this is a retrospective crosssectional quantitative study design that used the latest nigeria demographic health survey 2018 kaplanmeier survival estimates logrank test statistics and the cox proportional hazards were used to assess the geographic and socioeconomic differences in the survival of children underfive in nigeria the kaplanmeier survival estimates show most underfive mortality occur within 12 months after birth with the poorest families most at risk of underfive mortality while the richest families are the least affected across the geographic zones and household wealth index quintiles the cox proportional hazard regression model results indicate that children born to fathers with no formal education hr 1360 95 ci 11331631 primary education hr 1279 95 ci 10561550 and secondary education hr 1204 95 ci 10201421 had higher risk of underfive mortality compared to children born to fathers with tertiary education moreover underfive mortality was higher in children born to mothers age ≤ 19 at first birth hr 1144 95 ci 10411258 of the six geopolitical zones children born to mothers living in the northwest region of nigeria had 634 hr 1634 95 ci 12382156 higher risk of underfive mortality than children born to mothers in the south west region of nigeria there is a need to focus intervention on the critical survival time of 12 months after birth for the underfive mortality reduction increased formal education and target interventions in geopolitical zones especially the north west north east and north central are vital towards achieving reduction of underfive mortality in nigeriahazard ratio lmic lowandmiddleincome countries sdgs sustainable development goals u5mr underfive mortality rate who world health organization globally geographic and socioeconomic differences in childhood mortality are a major public health concern especially in lowand middleincome countries lmics 13 geographic inequalities in mortality in lmics are usually substantial and partly explain socioeconomic differences in childhood mortality 4 according to the world health organization who children in developing countries are 10 times more likely to die before their fifth birthday compared with children in developed countries 25 in subsaharan africa regions 1 in 8 children dies before age five which is nearly 20 times the average of 1 in 167 for developed regions 56 there has been a substantial decline in childhood mortality on the global stage 7 the high rate of childhood mortality in nigeria 132 deaths per 1000 births is still one of the main public health concerns 8 in nigeria every minute one child under5 years dies ie 1440 deaths daily 9 given that the childhood mortality rate is a major

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studying potential influences on adolescent substance use within this framework child characteristics remain influential on development but are constantly being affected by forces within a childs proximal and more distal ecology consistent with a developmental psychopathology perspective we emphasize the changing relative impact of ecological forces on child development with family factors taking on a more prominent role in early childhood and peer and neighborhood factors becoming more critical during middle childhood and adolescence as youth spend more time away from home theoretical models of adolescent substance use also have supported a developmental psychopathology perspective tarter has proposed that multiple domains of risk generate liability for substance use disorders additionally shers devianceprocess model simultaneously incorporates individual characteristics family history and environment and academic and peer environments in this model substance use develops within the context of antisocial behavior with negative family and individual characteristics leading to affiliation with deviant peers which in turn is hypothesized to result in increased risk for substance use empirically this model is well supported but the vast majority of research testing this model has been initiated during adolescence rather than earlier in childhood research on the developmental antecedents of substance use has rarely prospectively examined risk factors from multiple domains and beginning as early as early childhood exceptions to this trend are recent studies that test cascade models to study risk factors for adolescent substance use in such models risk factors assessed in early childhood are hypothesized to lead to risk factors assessed in early then later middle childhood and ultimately to adolescent substance use for instance dodge and colleagues found that nonsupportive parenting in early childhood was associated with externalizing problems at school entry and consequently problems with peers schoolage peer problems were associated with deviant peer affiliation and exacerbated nonsupportive parenting during later middle childhood and adolescence increasing the likelihood of adolescent substance use martel and collegues have also utitlized a cascade model to investigate adolescent substance use in their study temperament traits between 3 to 5 years of age were affiliated with later innattention and disruptive behavior which were linked with adolsecent substance use finally researchers investigating child maltreatement as a risk factor for later cannibas abuse and dependence utilized a cascade model to suggest that maltreatment prior to ages 7 to 9 increased the likelihood of externalizing problems in middle childhood and early adolscence leading to subsequent cannabis use these three studies demonstrate the utility of taking a developmental cascade approach emphasizing the role of both child and ecological factors in pathways to substance use trajectories from early childhood to adolescence however with the exception of the study by study martel and collegues which measured child temperament prior to age 5 none of the other studies assessed child attributes in early childhood in addition none of the three studies prospectively measured ecological influences prior to age five it is likely that many of the risk factors purported to emerge at school entry may be identifiable in early childhood as risk factors for emerging adolescent antisocial behavior have been found for children as young as 2 to 3 years of age this earlier identification could inform prevention efforts to disrupt the cascading pathway leading to substance use outcomes the purpose of this paper is to identify pathways leading to the use of alcohol tobacco and marijuana during adolescence by exploring developmental pathways from very early childhood through adolescence precursors of adolescent substance use a key challenge to understanding early antecedents of adolescent substance use within a developmental psychopathology framework is the limited research on early childhood predictors with the vast majority of studies being initiated during adolescence however studies examining the structure and comorbidity of adult psychopathology the hierarchical structure of child psychopathology and behavioral genetic studies of externalizing problems all suggest that substance use overlaps considerably with antisocial behavior and that both categories of behavior share common risk factors moreover as conduct problems and more serious antisocial behavior are strong risk factors for later substance use and many studies examining externalizing utilize measures that include substance use it is logical to assume that risk factors for substance use during adolescence overlap to a moderate degree with risk factors for antisocial behavior thus where available we examine studies investigating risk for substance use and where the literature is lacking we utilize research examining early predictors of youth antisocial behavior to guide the present inquiry early childhood precursors early conduct problems conduct problems in early childhood have been linked to substance use in adolescence both theoretically and empirically consistent with research linking earlystarting patterns of conduct problems to more serious antisocial activities during adolescence earlystarting antisocial behavior has repeatedly been shown as a risk factor for adolescent substance use behavioral problems at age 3 have been longitudinally linked to drug and alcohol use as early as age 14 and these early behaviors are linked to increased rates of alcohol dependence at age 21 in community samples studies utilizing high risk samples including children of alcoholic fathers have shown that it is not just initial behavior problems at preschool age but also a persistence of problem behavior over time that predicts adolescent substance use considering the links between early problem behavior and adolescent substance use it is also not surprising that antisocial behavior and delinquency during adolescence are also well established individuallevel risk factors for adolescent substance use additionally studies examining the relationship between externalizing behavior and parenting another precursor of adolescent substance use indicate the presence of a reciprocal relationship between the two constructs with childrens early externalizing problems increasing the likeliness of later harsh parenting parenting it is clear that early individual risk factors are likely to partially account for the persistence and expansion of problem behavior across developmental periods however familylevel factors also have been found to contribute to risk for adolescent substance use for example parental monitoring during both middle childhood and adolescence has been found to be a protective factor for adolescent substance use and there are strong theoretical reasons and indirect empirical support to suggest indirect or even direct links between parenting practices during early childhood and adolescence substance use unfortunately there are relatively few studies that have examined direct or indirect paths between early caregiving practices and youth substance use the few studies that have investigated associations between early parenting and adolescent substance use focus on the presence or absence of positive parenting as previously mentioned dodge and colleagues found that nonsupportive parenting at school entry was associated with later adolescent substance use via deviant peer affiliations and problem behavior shelder and block found that observations of parentchild interactions in preschool characterized by low levels of maternal responsiveness warmth and acceptance were associated with higher levels of drug use at age 18 finally baumrind found that 15 yearold adolescents that did not use drugs were more likely to have authoritative parents at age 4 than those who did use drugs in the baumrind study parenting style was found to be relatively stable from early childhood to adolescence the latter of which was also associated with adolescent substance use although studies of early parenting behavior and adolescent substance are limited they do suggest that early parenting characterized by high levels of responsivity supportiveness and acceptance is related to reduced risk of later substance use for the purposes of this paper parenting practices that are considered to be high in responsivity support and acceptance will be deemed nurturant parenting furthermore as parenting practices between the ages of 2 and 3 have been repeatedly related to earlystarting pathways of antisocial behavior it follows that similar associations could be evident for adolescent substance use moreover as studies emphasizing the contribution of early parenting behaviors for risk of later antisocial behavior have led to increasing emphasis and success using early preventive interventions understanding the role of early parenting especially as it is related to risk factors for substance use assessed later in development could be critical to understanding substance use and preventing its onset theoretically from social learning and attachment models one might expect similar processes leading to the development of antisocial activities from early childhood through adolescence to generalize to the use of substances although dodge and colleagues assessed negative parenting behaviors it is possible that positive parenting could follow a similar cascading pattern in which effective parent management strategies and secure parentchild attachments would be expected to set into motion a series of protective factors from cascading risks with early nurturant parenting protecting against early and continuing child oppositional and aggressive behavior rejection from prosocial peers and acceptance from deviant peers and subsequently such antisocial activities as substance use developmental continuity in early nurturant parenting would also be expected taking the form of involved parenting during early adolescence characterized by high levels of monitoring during adolescence which would serve as a buffer from adolescents involvement with deviant peers and engagement in deviant activities evidence suggests that early individual and family risk factors of antisocial behavior affect later risk factors through indirect and direct pathways maternal depression akin to parenting in early childhood affecting risk for adolescent substance use it is likely that parental depression particularly maternal depression would initiate a similar process in which high levels of depressive symptoms would compromise parental caregiving quality and lead to increases in child disruptive behavior and affiliation with deviant peers in fact beginning in middle childhood research has supported an association between clinical levels of maternal depression and later substance use problems with children of a clinically depressed mothers being five times more likely to experience alcohol dependence during adolescence than children whose parents are not clinically depressed in addition to clinical diagnosis levels of maternal depressive symptoms in a community sample during middle childhood have been linked to youth substance use by the seventh grade although there is little research examining associations between maternal depression during early childhood and adolescent substance use via either direct or indirect pathways of risk factors measured during early adolescence in studies of earlystarting antisocial behavior parental depression has been shown to set a series of such risk factors in motion as decreased positive parenting and links to later externalizing behaviors thus we expected that maternal depression during early childhood would be indirectly related to adolescent substance use via associations with parenting and externalizing behavior problems during adolescence adolescent precursors sensation seeking beginning during middle childhood and continuing during adolescence sensation seeking is an individual risk factor that has frequently been associated with both substance use and delinquency characterized by a preference for high levels of novel stimulation and risk taking and thought to be driven by cortical underarousal in brain functioning the association between sensation seeking and substance use appears consistent longitudinally research from crawford pentz chou li and dwyer suggest that sensation seeking assessed as early as middle school predicted increases in alcohol and marijuana use as well as initial cigarette use during later adolescence in a sample of typical children other researchers have found that sensation seeking in the 4th and 5th grades has an indirect effect on substance use in the 11th and 12th grades via deviant peer associations in 7th through 10th grades for the purposes of this study sensation seeking was assessed during emerging adolescence using the daring factor derived from the child and adolescent disposition scale which akin to sensation seeking assesses youth preferences for high levels of novel stimulation and risk taking additionally as emerging adolescence was the earliest that propensity for daring was measured the hypothesized model in this study includes a pathway from externalizing in early childhood to daring during emerging adolescence to account for previously established correlations between daring and externalizing parental knowledge as previously mentioned longitudinal links have been consistently established between parental monitoring of adolescents activities and whereabouts as a protective factor from adolescents initial and continued use of substances with some data to suggest that monitoring is particularly salient for youth at highest risk for using substances theoretically this link is consistent with emerging adolescents increasing mobility and time spent with peers outside of the home including exposure to deviant peers and deviant activities such as substance use thus parental monitoring during adolescence has been found to be negatively associated with adolescents tobacco alcohol and marijuana use directly and indirectly via deviant peer affiliation stattin and kerr have posited that parental knowledge a specific aspect of parental monitoring that addresses parental awareness of childrens activities resulting from children disclosing information to their parents is a more robust predictor of deviancy when compared to other measures of monitoring that investigate only parents surveillance and tracking of their children studies are needed that incorporate both parental awareness and child disclosure as potential buffers from adolescent substance use peer influences in addition to individualand familylevel risk factors deviant peer affiliation has also been shown to be a robust predictor of adolescent substance use for example longitudinally deviant peer group membership at ages 15 and 16 predicted substance use at 18 years of age furthermore peers substance use a specific form of deviance has been found to be a consistent predictor of adolescent substance use whereas research supports peer substance use as a critical risk factor for adolescent substance use some have suggested that the influence of peer substance use may be overestimated because much of the extant research has failed to distinguish between adolescents perceptions of peers substance use and peers actual substance use creating a potential selection bias research from iannotti and bush support this claim that perceptions of peer use and actual peer use independently contribute to adolescent substance use in their study perceptions of peer use were more highly correlated with adolescents use of tobacco alcohol marijuana and cocaine when compared to actual peer use additional studies are needed that can simultaneously address the influence of both perceptions of peer substance use and peer report of substance use the current study the purpose of this paper is to identify developmental pathways leading to the use of alcohol tobacco and marijuana during adolescence by testing a cascading model of risk from very early childhood through adolescence developmental cascades models emphasize the potential for one domain of development to sequentially influence additional domains of development leading to increased risk of a problem behavior cascade models routed in conservative theory generally include three or more domains of development three or more developmentally salient time points and predict across domains while controlling for withintime covariance across domains and change within the domain itself alternatively many researchers have utilized cascade models to look at developmental processes without strict adherence to all of the previously mentioned criteria the current study utilizes a cascade approach to investigating risk for adolescent substance use recognizing that all three domains of development assessed are not all assessed at all three time points based on research emphasizing established links between intraindividual risk caregiving risk and protective factors peer risk and substance use in adolescence and between many of these risk factors examined in early childhood and adolescent antisocial behavior the current study addresses how risk factors in early childhood indirectly contribute to the prediction of substance use during adolescence through their effects on risk factors during emerging adolescence in addition we also reexamine associations between established correlates of adolescent substance use during emerging adolescence while controlling for risk factors in earlier childhood the sample includes an ethnically diverse lowincome cohort of boys at heightened risk for antisocial behavior problems and takes advantage of extensive longitudinal data collected from observational and multiple reporters across a 15year period where both direct and indirect contributions of early risk factors can be assessed the following hypotheses focusing on cascading processes guided the current study 1 it was expected that early externalizing problems would be linked to later substance use via emerging adolescent individual characteristics and parental knowledge 2 it was anticipated that nurturant parenting in early childhood would be negatively related to adolescent substance use and that this relationship would be mediated by lower levels of youth externalizing problems in emerging adolescence higher levels of parental knowledge during midadolescence and lower levels of peer substance use during midadolescence 3 it was expected that mothers early depressive symptoms would be indirectly related to adolescent substance use in adolescence through higher levels of externalizing problems during emerging adolescence and lower levels of parental knowledge in midadolescence 4 it was hypothesized that the relationship between daring and externalizing problems in emerging adolescence and later substance use would be partially mediated by peer substance use additionally it was predicted that boys externalizing problems during midadolescence would be negatively related to levels of parental knowledge methods participants and procedures this study used data from the pitt mother and child project an ongoing longitudinal study on vulnerability and resiliency in boys from lowsocioeconomic backgrounds participants were recruited from the allegheny county women infants and children program in the pittsburgh metropolitan area as the original intent of the study was to examine precursors of antisocial behavior the study was restricted to boys a sample of 310 families with 1½ year old sons participated in the study fiftythree percent of the target children in the sample were european american 36 were african american 5 were biracial and 6 were of other races at the initial assessment when boys were 18 months old the age of mothers ranged from 1743 years and two thirds of mothers in the sample had 12 years of education or fewer when the boys were 18 months 44 of the mothers indicated that they were married 21 were living together and the remaining 35 were single separated or divorced the mean per capita income was 241 per month and the mean hollingshead ses score was 245 indicative of impoverished to working class for the present study data from assessments at ages 15 2 35 11 12 15 and 17 were utilized retention rates have been generally high at each time point with 89 of the initial 310 participants completing assessments at ages 11 or 12 years and some data available on 87 and 81 of participants at 15 and 17 years of age families that did not complete assessments at later ages did not differ on variables included in the study from those whom complete data were available therefore all 310 families were included in the final analyses for the current study target children and their mothers were seen in the home andor the lab for 2to 3hour visits at ages 15 2 35 11 12 15 and 17 years old during these assessments mothers completed questionnaires regarding sociodemographic characteristics family issues and child behavior assessments at ages 15 2 35 and 11 were conducted in the lab and all other visits were conducted in the participants homes including a combined homelab assessment at age 2 which featured observations of the quality of the home environment and parentchild interaction during structured tasks and during an interview with the mother during the age 15 assessment questionnaires were also completed by a peer of the target child whom the target child identified a friend with whom he spends considerable time participants who had missing data at ages 15 and 17 did not differ from the rest of the sample in relation to ses race marital status or any other study variables measures early childhood nurturant parenting nurturant parenting at age 2 was derived using the nurturance factor from the home observation for measurement of the environment the home assesses the quality and quantity of support and stimulation in the childs home environment using observations and parent interview the nurturance score was obtained by calculating separate means for the responsivity and acceptance subscales for the 11item responsivity scale examiners rated parents emotional and verbal responsivity to the child with such items as parent responds verbally to childrens verbalizations and parent spontaneously praises child at least twice examiners assessed parents acceptance of the childs behavior using the 8item acceptance subscale which was comprised of items such as parent does not shout at child and parent does not express overt annoyance with or hostility to the child mothers depressive symptomatology mothers completed the beck depression inventory a widely used measure of depressive states during study assessments when their sons were 15 2 and 35 years mothers rated the intensity of 21 symptoms and characteristics of depression on a 4 point likert scale ranging from 0 to 3 responses were summed so that higher scores reflect higher levels of depressive symptoms externalizing problems mothers completed the child behavior checklist 23 during study visits when their sons were 2 and 35 years of age from which the broadband externalizing factor was used for the present study the cbcl is a widely used parentreport measure of child adjustment problems in which parents of preschool age children respond to items regarding their childs behavior within the past 2 months using a 3point likert scale ranging from 0 to 2 cronbachs alphas for the externalizing factor at ages 2 and 35 were 88 and 85 respectively tscores were used for analyses covariates families socioeconomic status at 15 years of age was calculated using the mean hollingshead fourfactor index score and used as a covariate in the final structural model targets race was dummy coded for european american and other ethnicities finally mothers age at 15 years of age was also included in the final structural model adolescent measures externalizing problems to provide an assessment of broadband disruptive behaviors the externalizing factor was derived from the child behavior checklist age 418 version mothers reported on their sons behavior when boys were 11 and 12 years of age tscores were used for analyses adolescent daring daring was assessed at age 12 using the 5item factor of the same name from the child and adolescent disposition scale both parent and target youth report were utilized respondents rated each item on how well the emotion or behavior describes the target youth on a 4point likert scale ranging from 1 to 4 examples of items include is heare you daring or adventurous and does hedo you enjoy doing things that are risky and dangerous a mean score was calculated for mother and target youth report separately parental knowledge at age 15 target youth were asked a series of questions about their parents monitoring of their whereabouts and of their disclosure of their activities to their parents using an interview developed by dishion patterson stoolmiller and skinner youth rated parental monitoring using five items and rated youth disclosure using four items on a 5point likert scale ranging from 1 to 5 means for monitoring and youth disclosure items were calculated separately perceptions of peer substance use youth perceptions of peer substance use were assessed at age 15 for their selfidentified neighborhood and school peer groups youth were asked to indicate separately on a 4point likert scale how often in the past 6 months their school peer group and neighborhood peer group drank alcohol and used marijuana scores for alcohol use and marijuana use were highly correlated for both school peers and neighborhood peers and were therefore averaged to create a composite perceptions of substance use score for both school and neighborhood peers peer substance use substance use of peers invited to the age 15 assessments by target youth was assessed using five items from the self report of delinquency peers were asked to indicate the extent to which they had engaged in various delinquent behaviors during the past year using a 3point rating scale peers were asked separate questions for drinking beer wine and liquor to aggregate these three questions into a single measure of alcohol use the highest rated item was used to represent the extent of overall alcohol use peers also indicated their tobacco use and marijuana use cronbachs alpha for these three items was 84 youth substance use youth reports of substance use at age 17 also were assessed using the srd the same measures administered to peers at age 15 additionally youth were asked to indicate if they had used cocaine glue lsd heroin ecstasy or methamphetamine in the past year however we chose to only focus on alcohol marijuana and tobacco use because of the extremely low base rate of other substances all of which were less than 2 data analysis plan mplus 52 was utilized to conduct the structural equation modeling for these analyses prior to testing sem models log transformations were conducted on the externalizing problems and mothers depressive symptoms variables to correct for their nonnormal distribution missing data were determined to be missing at random as per recommendations by shafer and graham and acock prior to computing the full sem model latent factors were constructed for mothers depressive symptomatology nurturant parenting childhood externalizing problems early adolescent externalizing problems daring perceptions of peer substance use peer report of substance use and target youth report of substance use the early childhood and early adolescent factors were created by treating each age point that data were collected for that measure as an indicator variable by using this method the latent variable is indicative of the behavior during the entire age span of the indicator variables this approach was used because for the purposes of this study the interest of the effect of the predictor variables on substance use was not specific to one age but to the developmental periods of early childhood and emerging adolescence the use of latent variables also served to rectify such instances in which the alpha for one of the indicator values was less than 07 which was found for adolescent daring and nurturant parenting for all variables for which only two indicators were available the pair of indicators were treated as parallel such that each manifest variable was fixed to one to load equally onto the latent construct additionally target and peer responses to their alcohol tobacco and marijuana use were treated as categorical indicators because there was not an equidistant spacing between the thresholds for each response based on recommendations from cole and maxwell a measurement model was first tested in which all latent variables were permitted to correlate with one another next to capture a developmental psychopathology framework in which risk factors from multiple domains at earlier developmental periods are hypothesized to influence risk factors at later periods a fully saturated structural equation model was tested that included direct pathways from all upstream variables to all downstream variables finally a restricted structural model that reflected the proposed hypotheses was tested specifically following the first hypothesis early externalizing problems were modeled as a predictor of adolescent daring externalizing problems and parental knowledge following the second hypotheses pathways from nurturant parenting to adolescent externalizing problems parental knowledge perceptions of peers substance use and peers selfreport of substance use were included in the model based on the third hypothesis mothers early depressive symptoms were modeled as predictors of later externalizing problems and parental knowledge in addition pathways from daring to perceptions of peers substance use and peers report of substance use and pathways from adolescent externalizing problems to subsequent parental knowledge perceptions of peers substance use and peers report of substance use were included finally pathways from all earlier variables to substance use at age 17 were retained in the final model both the fully saturated and the hypothesized restricted model included withintime correlations of residual covariances among constructs for instance the correlations between the residual covariances among early externalizing problems nurturant parenting and mothers depressive symptoms were freely estimated finally covariates for ses mothers age and target childs ethnicity were included in both models a weighted leastsquares with mean and variance adjustment estimator was used to estimate the structural model according to the recommendations of muthén dutoit and spisic because it provides useful fit indices that are advantageous with categorical indicators such as those that comprised the target youth and peer substance use factors to evaluate the fit of the structural models several fit indices were used including the chisquare goodness of fit statistic the root mean square error of approximation the tuckerlewis index and the comparative fit index all of which have been typically used as indices of practical fit finally to test for mediation the paths from the independent variables were freed and estimated bootstrapping was used to test for indirect effects results table 1 provides descriptive data for the categorical substance use data specifically the proportions of responses from targets and peers reporting their frequency of alcohol tobacco and marijuana use as none one to two times or more often are listed additionally the combined proportions of responses indicated one to two times and more often are provided in the total use column finally the proportion of individuals reporting use of any substance within the past year is also listed with target youth and peers reporting 60 and 41 percent of some form of substance use in the past year respectively for all substances reported target youth at age 17 reported higher proportions of use than peers at age 15 table 2 provides descriptive statistics for all remaining continuous indicators used in testing the theoretical model as per the recommendations of cole and maxwell a measurement model was first computed to ensure that the manifest variables were related to one another the measurement model suggested an acceptable model fit and the loadings of the resulting latent factors are presented in table 3 next an unrestricted saturated model was computed and fit indices suggested acceptable model fit finally the restricted hypothesized model was computed and the difftest command in mplus revealed no significant differences between the saturated model and the restricted hypothesized model therefore the restricted model was retained as the final model the covariance coverage of data ranged from 73 to 98 and the practical fit indices indicated that the final model provided an acceptable fit to the data the amount of variance explained had the following r 2 estimates for externalizing problems and daring in emerging adolescence r 2 estimates were 30 and 03 respectively for parental knowledge the r 2 estimate was 22 for perceptions of peers substance use and peers substance use r 2 estimates of 04 and 05 were obtained for substance use the r 2 estimate was 58 correlations among latent variables are presented in table 4 all three early childhood constructs were significantly correlated with one another with nurturant parenting being negatively correlated with externalizing problems and mothers depressive symptomatology and externalizing problems and mothers depressive symptoms being positively correlated among risk variables assessed during adolescence daring was related to adolescent externalizing problems and both peers substance use and targets perceptions of peer substance use were significantly correlated of the early childhood precursors nurturant parenting and externalizing problems were correlated with later substance use adolescent risk variables assessed at ages 1215 were each related to target youth substance use at age 17 figure 2 presents the results of the final multivariate structural model although only significant level pathways are shown in figure 2 all of the pathways for the final structural model are presented in table 5 significant pathways from early externalizing problems to adolescent externalizing problems and parental knowledge emerged nurturant parenting was positively related to parental knowledge in adolescence greater mothers depressive symptomatology during early childhood predicted higher levels of early adolescent externalizing problems adolescent externalizing problems were negatively associated with later parental knowledge direct pathways to target youths report of substance use at age 17 were evident for daring parental knowledge perceptions of peers substance use and peers report of substance use higher rates of daring perceptions of peer substance use and peers report of substance use and lower rates of parental knowledge were related to increased substance use within the model finally the indirect effects are reported in table 6 parental knowledge significantly mediated the relationships between early externalizing problems and substance use and adolescent externalizing problems and substance use trend level mediation only was evident in all additional indirect effects explored discussion the current findings contribute to the field by demonstrating that pathways leading to adolescent substance use can begin to be established beginning as early as the toddler period and progress in a catenated fashion throughout development the sample itself was selected on the basis for being at risk for antisocial behavior a strong correlate of adolescent substance use as researchers of adolescent substance use have recommended multiple developmental influences were examined simultaneously which included the use of multiple informants and methods to reduce informant and method bias hypothesis 1 early externalizing problems as a risk factor for adolescent substance use the first hypothesis of the current study was that relationship between externalizing problems in early childhood and later substance use would be mediated by adolescent externalizing problems daring and parental knowledge partial support was found for this hypothesis as early externalizing problems were related to higher levels of early adolescent externalizing problems and parental knowledge in middle adolescence however no direct pathway from early adolescent externalizing problems to substance use was evident in the final model instead parental knowledge sequentially mediated the relationship between adolescent externalizing problems and substance use highlighting the protective role of positive parenting in adolescence it is noteworthy that the pathway from early childhood externalizing problems to parental knowledge was positive such that higher levels of early externalizing problems in early childhood were associated with higher levels of parental knowledge however a negative relationship was found between early adolescent externalizing problems and parental knowledge although past research even within the current sample has indicated that parents of emerging adolescents with externalizing problems are less involved with their children if high levels of disruptive behavior are perceived by parents during early childhood it may elicit more rather than less parental involvement and knowledge of childrens activities during adolescence studies of reciprocity between early externalizing and parenting behaviors often focus on early externalizing eliciting later negative and harsh parenting behaviors it is possible that early externalizing does not have the same effect on positive parenting behaviors and the negative relationship between the externalizing and parenting is only evident when adolescent behaviors are accounted for clearly research further exploring this relationship is warranted even though during adolescence parents with disruptive toddlers showed higher levels of parental knowledge early externalizing problems during early childhood were positively correlated with substance use at age 17 and parental knowledge during midadolescence served to mitigate this relationship despite past research suggesting that individuals who have high levels of sensation seeking and daring are more likely to exhibit delinquent behavior there was no direct link between externalizing problems in early childhood and daring during emerging adolescence in the final model these results for daring lend support to researchers who have suggested that the propensity for daring activities and sensation seeking is an aspect of ones temperament and less predicated by earlier experiences although this might account for nonsignificant associations in the links between daring and early indices of parenting a modest association was expected from early child externalizing problems as a proclivity to engage in high stimulus activities is thought to be one of several components underlying early disruptive behavior perhaps by age 2 and 35 when early externalizing problems were assessed this component of disruptive behavior is not fully established regardless the results from this study support externalizing problems in early childhood as a precursor to adolescent substance use these results are not surprising based on the extent of research linking early behavior problems to adolescent substance use and abuse but results from the current study extend these findings back to early childhood hypothesis 2 nurturant parenting as a protective factor for adolescent substance use the second hypothesis of the current study was that nurturant parenting in early childhood would be negatively and indirectly related to adolescent substance use via associations with higher levels of parental knowledge and lower levels of peer substance use during midadolescence and youth externalizing problems in emerging adolescence nurturant parenting at age 2 was not related to lower levels of externalizing problems or peers substance use in adolescence however as expected there was continuity between nurturant parenting at 2 years of age and parental knowledge during adolescence which in turn was associated with decreased adolescent substance use unexpectantly nurturant parenting in early childhood was positively correlated with substance use at age 17 however after controlling for the other variables in the final model the direct pathway between nurturant parenting and substance use was insignificant indicating that the positive relationship between early parenting and substance use may be spurious in nature as previously discussed parental knowledge also served as the factor linking both early childhood and early adolescent externalizing problems to substance use these findings are consistent with previous literature emphasizing the importance of parental knowledge during adolescence as a robust predictor of youth substance use but also further extend its importance by showing parental knowledge to be a critical link that buffers the risk of multiple types of early childhood risk on adolescent substance use hypothesis 3 mothers early depressive symptoms as a risk factor for adolescent substance use the third hypothesis was that mothers early depressive symptoms would be indirectly related to substance use in adolescence through links with higher levels of externalizing problems in emerging adolescence and lower levels of parental knowledge in middle adolescence a positive path emerged between mothers early depressive symptoms and boys later externalizing problems although such paths have more routinely been investigated for parenting in relation to antisocial behavior these results suggest that similar pathways emerge in the relationship between early maternal depressive symptoms and later adolescent substance use specifically a pathway was evident from early maternal depressive symptoms to later externalizing problems and from later externalizing problems to parental knowledge and finally from parental knowledge to adolescent substance use this pathway to adolescent substance use is consistent with recent work showing that changes in maternal depressive symptoms mediated improvements in toddler age externalizing problems among a sample of extremely highrisk male and female toddlers recruited on the basis of sociodemographic family and child risk factors hypothesis 4 daring and externalizing problems in emerging adolescence as risk factors for adolescent substance use the final hypothesis was that relationships between daring and externalizing problems in emerging adolescence and later substance use would be partially mediated by associations with peer substance use and that parental knowledge would mediate the relationship between adolescent externalizing problems and later substance use support was found only for the latter part of this hypothesis surprisingly neither externalizing problems nor daring in adolescence were associated with perceptions of peers substance use or peers selfreports of substance use in the final model it was expected that individuals with higher levels of externalizing problems would be more likely to associate with peers who use substances given adolescents tendency to associate with peers with similar levels of antisocial behavior however no support for such an association was found in the structural model or the correlations between the constructs similarly it was surprising that no significant pathways from daring to either youths perceptions of peer substance use or peers selfreports of substance use were evident in the final model as researchers have reported that adolescents tend to seek out and affiliate with peers with similar levels of daring and sensations seeking one might expect this association to emerge based on common characteristics future research on this topic is recommending before drawing definitive conclusions however the current findings suggest that although both daring and peers use of substances predict substance use independently these two correlates were unrelated to one another in the multivariate model furthermore it is noteworthy that the measures of peer problem behavior were specific to peers use of substances it is possible that pathways between daring and peer problem behavior in the structural model may have emerged if a broader measure of peer deviant behavior had been utilized as sensation seeking and daring are associated with a multitude of deviant and risky behaviors beyond substance use the same may be true of the modest relationship found between externalzling problems and peer susbtance use more research is needed to determine if such a relationship would be evident using a more general scale of problem behavior conversely the hypothesis that parental knowledge would mediate the relationship between adolescent externalizing problems and substance use was fully supported as previously mentioned parental knowledge fully mediated this relationship resulting in a nonsignficant direct pathway from adolescent externalizing problems to substance use although the nonsignificant pathway from externalizing problems to substance use was surprising these results again highlight the important preventive role of parental monitoring and child disclosure during the adolescent years parental knowledge has been associated with parents and adolescents spending more time together and increased enjoyment derived from these interactions it is likely that the positive aspects of the parentchild relationship associated with higher levels of parental knowledge also contribute to the attenuation of the relationship between externalizing problems and later substance use adolescent predictors in the final structural model both youth perceptions of their peers substance use and peers selfreport of substance use were found to be reliable predictors of youth substance use direct pathways to adolescent substance use from youth perceptions of peers substance use and peers selfreport of substance use remained significant despite the inclusion of one another in the final model lending support to previous literature suggesting that perceptions of peers drug use and peers actual drug use are not necessarily synonymous in their influence on adolescent drug use thus future research should be clear in its distinction of these two constructs as they are not tantamount to one another moreover the results suggest that drug prevention programs should target both perceptions of peers use and peer affiliation in addition to the direct and indirect pathways leading to substance use that emerged from the structural model it is also important to consider that some researchers consider experimental use of substances during adolescence a normative and healthy aspect of development whereas this may be true associations between substance use and risk factors for psychopathology were evident in the current sample although not a focus of the current paper youth reports of substance use were significantly correlated with concurrent selfreports of depressive symptoms and anxiety symptomatology as well as both parent and youth reports of antisocial behavior considering their already heightened risk for mental health problems it is likely that for male adolescents from predominantly lowincome families even experimental substance use is associated with multiple types of maladaptive outcomes during adolescence limitations and future directions although the current study has many strengths incorporating 15 years of longitudinal data with an atrisk sample of male youth using multiple informants and methods as well as a developmentally informed model there are several limitations that need to be considered when interpreting the findings as noted above the original study from which participants were drawn was designed to investigate the precursors of childhood antisocial behavior and thus recruited only boys from lowincome families living in an urban setting therefore the findings may not be generalizable to girls children from higher ses samples or nonurban settings future studies should investigate whether similar processes in early childhood are indicative of adolescent substance use second the current study utilizes targets report of alcohol tobacco and marijuana use at age 17 only this study does not examine clinical diagnoses of substance use disorders age of first use the recreational use of prescription drugs or the use of other illicit drugs and therefore findings cannot be generalized to these outcomes future studies should investigate whether a similar process is evident in these heightened risk groups at such a young age moreover it is possible that by not accounting for substance use at earlier ages that associations found with substance use at age 17 could be overinflated additionally the measure for substance use itself was less than ideal the response to frequency of use was rather limited and did not capture specific frequencies of use although other studies have also assessed frequency of substance using the same number of categories future studies should include measures that provide more detailed information regarding adolescents substance use nevertheless results suggest that early child indicators are precursors of later substance use even with this limited measure it is also possible that additional factors are influential in the development of adolescent substance use for instance although the purpose of this study was not to study high risk children of alcoholics future studies should investigate whether similar pathways emerge for this population that is at both increased genetic and environmental risk of later substance use regardless of clinical levels of parental substance use it is likely that parental use of any substances would be influential to adolescent substance use the lack of inclusion and availability of these data is a limitation of this study finally as was previously discussed the target youth at age 17 reported higher rates of substance use when compared to their peers at 15 years of age although this was previously attributed to the difference in ages at the time of report it is also possible that the peers who were participating in the study for the first time at age 15 may have felt some reluctance to reveal their substance use to relative strangers compared to target youth who have been in the study for 15 years regardless even with the potential for peers underreporting direct pathways from peers selfreported substance use to targets substance use emerged in the final structural model conclusions and clinical implications in sum these findings provide novel information about early developmental pathways of adolescent substance use the use of prospective longitudinal analyses with multiple informants allowed us to investigate developmental pathways over a 15 year period these results are consistent with previous findings on the development of adolescent antisocial behavior by implicating individual familial and peer level riskfactors during childhood and emerging adolescence with later adolescent substance use furthermore the present study extends past research by documenting evidence of familial and individual riskfactors during early childhood these findings also provide targets for early intervention to prevent later adolescent substance use specifically they indicate that young children would benefit from interventions that focus on encouraging positive parenting behaviors and reducing maternal depressive symptoms two factors that have been implicated in the development of childrens early externalizing problems moreover by exploring predictors common between externalizing problems and substance use the current study supports the notion that research and prevention efforts for delinquency may have collateral effects on substance use

this study examined developmentallysalient risk and protective factors of adolescent substance use assessed during early childhood and early adolescence using a sample of 310 lowincome boys child problem behavior and proximal family risk and protective factors ie parenting maternal depression during early childhood as well as child and family factors and peer deviant behavior during adolescence were explored as potential precursors to later substance use during adolescence using structural equation modeling results revealed that early childhood risk and protective factors ie child externalizing problems mothers depressive symptomatology and nurturant parenting were indirectly related to substance use at the age of 17 via risk and protective factors during early and middle adolescence ie parental knowledge and externalizing problems the implications of these findings for early prevention and intervention are discussedsubstance use adolescents early risk factors longitudinal research despite current prevention efforts adolescent substance use remains prevalent in a recent study by the us department of health and human services 2010 15 percent of 1217 yearolds report using alcohol 12 report using tobacco and 73 report using marijuana in the past month highlighting the number of youths affected these rates are concerning as adolescent substance use has been linked to both shortand longterm health social and economic problems for individuals and society cornelius et al 2008masten faden zucker spear 2008 including substance use disorders in adulthood newcomb bentler 1988 by identifying developmental precursors of adolescent substance use it may be possible to identify atrisk individuals and families when behavior is less entrenched and more malleable to preventative efforts reid 1993 although multiple risk factors for adolescent substance use have been established in adolescence hawkins catalano miller 1992 and to a lesser extent during middle childhood dodge et al 2009 relatively few studies have provided longitudinal data on predictors of adolescent substance use beginning in early childhood block

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background global ageing trends are resulting in increased challenges of providing healthcare for older populations particularly frail older people 1 as the population ages worldwide the number of people classified as frail also increases with a disproportionate rise in the burden across lowincome regions such as subsaharan africa 2 over the next three decades the second fastest rise in the number of older people is foreseen in ssa with an expected growth from 32 million in 2019 to 101 million by 2050 3 a recent review and metaanalysis on the prevalence of frailty in older people living in africa showed the rate of frailty is rising with an overall prevalence of 3864 citation by authors to remain anonymised the average life expectancy in ssa is higher than it was two decades ago which leads to a greater proportion of frail older people in the region 45 frailty is a strong predictor of adverse health outcomes including disability falls mortality hospitalisation and institutionalisation 6 7 8 9 10 consequently the development of a valid screening instrument to identify frailty is crucial for improving the health of frail older people at risk of adverse health outcomes there are a range of frailty instruments that can distinguish frail and nonfrail older people 11 12 13 14 15 these screening instruments reflect different operational definitions of frailty focusing on physical functioning 16 and application of multidimensional approach encompassing biological psychological and social domains 1718 however the validity of these instruments is subject to significant debate and not one instrument is considered the gold standard 1920 the multidimensional concept of frailty has been studied more recently 21 22 23 one of the multidimensional screening instruments the tilburg frailty indicator is a frailty assessment instrument with good psychometric properties 1421 and easy to administer and a userfriendly for assessing frailty in communitydwelling older people 21 moreover of the 38 multicomponent frailty assessment instruments the tfi has the most strong evidence for the reliability and validity of its psychometric properties 2425 the tfi was developed by gobben et al 22 based on the integral conceptual model of frailty 26 the tfi instrument contains 15 items that takes less than 15 minutes to complete the tfi has been used in clinical trials to identify frail participants monitor changes in frailty status over time and evaluate the effectiveness of interventions 27 28 29 the usefulness of the tfi in intervention studies also attributed to its ease of administration validity and reliability multidimensional nature and risk stratification 2130 the frail scale 31 edmonton frail scale 3233 clinical frailty scale 3435 groningen frailty indicator 3637 prisma7 38 and tilburg frailty indicator 39 40 41 instruments were cross culturally adapted to measure frailty the tfi was one of the multidimensional frailty measurement instruments translated and adapted for use in many nonenglish speaking european countries 2339 41 42 43 44 including asia 2545 and south america 46 to date the tfi has not been tested in any developing countries and has never been used in studies of ssa older people this study will be the first test of the tfi in a developing country specifically the subsaharan country of ethiopia this study aimed to translate the tfi into amharic the national language of ethiopia to undertake a crosscultural adaptation and determine the validity and reliability of the tfi for use in ethiopia the research team are undertaking this study to enable them to use the tfiam version to measure the outcome of their nurseled frailty intervention study in ethiopia citation by authors remains anonymised methods study setting design and period the methodological research design used included translating and adapting the original english language version of the tfi into amharic language and undertaking validity and reliability testing of the tfiam version the study was carried out using a crosssectional study design with older people living in bahir dar city amhara region ethiopia from october to november 2022 eligibility criteria the year that old age commences is determined by a setting and the formal cutoff point legislated in social policy for each country 47 in ethiopia the cutoff point for old age is 60 years 4849 the inclusion criteria for this study were older people 60 years or over residing in bahir dar ethiopia who were communitydwelling able to communicate verbally not wholly immobile and intact cognitive status sample size and procedures in previous studies it has been found that a sample size of 50 or more is needed for a reliability estimate of an instrument 4150 furthermore for the calculation of a reliability coefficient on a scale measurement a sample size of 50 and more is sufficient 50 moreover other studies suggest the minimum sample size should be at least five times larger than the number of variables being analysed 2541 the tfi consists of a total of 15 items that will be analysed therefore a minimum of 75 communitydwelling older people were required for this validity and reliability study to ensure a larger sample the data were collected from 96 communitydwelling older people living in bahir dar ethiopia after obtaining a written informed consent a survey conducted on convenient samples of communitydwelling older people using the new tfiam version the tfiam was administered using a facetoface interview technique conducted by a registered nurse who worked in a public health facility in bahir dar ethiopia this study was in complied with the declaration of helsinki instrument description the tfi comprises of 15 selfreported items separated into three distinct domains of health for older people physical domain consists of eight items related to the physical health psychological domain consists of four items related to the psychological health and social domain consists of three items related to social relations and social support eleven items of the tfi have two response categories of yes or no while three items from the psychological domain and one item from the social domain have three response categories as yes no or sometimes except item 19 in the tfi yes or sometimes responses were allocated a score 1 point each while item 19 in the tfi no and sometimes responses were allocated a score of zero for all other items no responses were scored as zero the instruments total score ranged from 0 to 15 the higher the score the higher ones frailty frailty is diagnosed when the total tfi score is ≥5 2241 instruments development language translation and adaptation written permission to perform the tfi translation and adaptation was obtained from the developer of the tfi 21 a standard guideline was used for translation and cultural adaptation of the original english language version of the tfi 5153 into amharic translators were given information regarding the instrument and the population to be investigated to make sure that the original concept underlying each item was maintained in the translation process 54 the translations emphasised the conceptual equivalent of a word or phrase not a wordforword translation 51 two amharicspeaking academics from universities in ethiopia who are fluent in english language independently translated the tfi english language version into amharic the translations from these two individuals were merged created into a single amharic form by a third person who is proficient both in english and amharic languages the tfi translated instrument created in amharic was back translated into english language by second person proficient in english and amharic languages who was not involved in the other stages of the translation the final english translated version from amharic was sent to the developer of the original tfi for approval before the reliability study was commenced the developer provided approval of tfiam version with no changes the final amharic version of the tfi was adapted and tested for its reliability on a selected sample of communitydwelling older people living in bahir dar ethiopia validity and reliability assessment validity validation of the instrument was completed before administration of the final tfiam instrument to any study participant face validity and content validity were used to test the validity of the tfiam to evaluate whether respondents had a clear understanding of the items in the instrument and the time required to complete the final translated and adapted tfiam version was piloted on a randomly selected sample of 20 older people living in bahir dar face validity the tfiam version was rated by eight healthcare professionals who are either currently working or who previously worked in primary healthcare including nurses community health workers public health professionals and public health researchers the raters were provided with a cover letter and response sheet the cover letter provided directions to guide them and outline their responsibilities on how to rate the face validity of the instrument in determining the face validity of the instrument the percentage of agreement between raters was calculated using each question and overall agreement using the equations below in determining the face validity of the instrument percentage of agreement less than 80 8089 and greater than or equal to 90 indicates a poor substantial and full strength of agreement respectively when items in an instrument are rated as a poor and substantial strength of agreement they need restructured and revised respectively 55 content validity the tfiam was rated by six researchers and healthcare professionals with expertise in community healthcare including the care of older people the group of raters consisted of professionals from nursing dietetics physiotherapy psychiatry and public health they were provided with a cover letter and response sheet the cover letter provided directions to guide them and outline their responsibilities on how to rate the content validity of the instrument they rated the items in the translated version in terms of clarity and relevance on a 4point scale as 5657 the item level content validity index was computed as the number of experts giving a rating 3 or 4 to the relevancy of each item divided by the total number of experts 56 the icvi values range from 0 to 1 where icvi 079 is acceptable and the item is relevant 070 to 079 items need revised and items with values below 070 need removed 56 a total content validity index average of the scale of 080 or higher was taken as an acceptable level 58 internal consistency the internal consistency of the instrument was measured after the data were collected from the eligible 96 communitydwelling older people who completed the tfiam version it was measured using the cronbachs coefficient alpha this statistic provides an indication of the average correlation among all of the items that make up the scale values range from 0 to 1 with higher values indicating the instrument is more reliability 59 cronbachs alpha values 060 060 to 070 070 to 080 080 to 090 and 090 and more indicate poor moderate good very good and excellent level of internal consistency respectively 6061 result sociodemographic characteristics a total of 96 older people were recruited to carry out the instrument adaptation validity and reliability testing more than sixtyfour percent of the study participants were female the mean age of the study participants was 6516 with age range from 60 to 88 years based on the tfi cutoff point of 5 for assessing frailty 552 of the study participants were frail of these 565 were female older people more than sixtyfour percent of the study participants were living with their spouse of these 548 were screened as frail more than 80 of the study participants had caregivers assistants to support them in their daily living more than 60 of those who had no care giver assistant were screened for frailty face validity five tfi items of the translated version of tfiam was between 80 and 89 the score of the five items of the tfiam was between 80 and 89 and the scores of the rest of each item were over 90 the overall scale agreement was found to be excellent with overall agreement of 958 the comments received on the readability and clarity of the items were discussed with the raters a minor revision on the five items whose score was between 80 and 89 was undertaken after a discussion with the raters content validity the item level content validity index and total content validity index average for the scale of the tfiam was rated the icvi of the tfiam revealed an acceptable value ranging from 083 to 10 and an scviave value of 091 reliability test statistics the total tfiam mean score was 576 there was a range in the mean scores across the tfiam domains the mean score of the physical domain which had eight items was the highest with 336 the psychological domain which has four items had a mean score of 132 and the social domain with three items had a mean score of 107 the internal consistency of the tfiam was very good with an overall cronbach alpha value of 082 the physical domain showed the highest reliability with a 075 cronbachs alpha value which corresponds to good reliability the psychological and social domains showed good and moderate reliability with cronbachs alpha value of 070 and 068 respectively the physical and psychological domain scores were strongly and positively correlated to the total tfi score r 091 p 001 and r 071 p 001 respectively the social domain score had moderate correlation with the total tfiam score r 041 p 001 the statistical characteristics of individual items in the tfiam and their mean ranged from 009 to 058 discussion several studies have indicated that the prevalence of frailty is increasing in the global ageing population 6263 commonly adopted frailty assessment instruments evaluate only physical frailty and report a lower rates of frailty in communitydwelling older people one would expect a higher rate of frailty with the tfi as it encompasses the psychological and social aspects of frailty 62 the proportion of frailty in the current study was 552 various validation studies on tfi in brazil 46 portuguese 41 and the netherlands 64 revealed more than 30 40 and 357 of older people with frailty the higher rates of frailty in the current study may be attributed to malnutrition in older people in the region being extremely high 65 the increasing burden of malnutrition and noncommunicable diseases coupled with insufficient access to 1122 healthcare and inadequate living condition for older people in ethiopia 6667 may contribute to higher rates of frailty however compared to the current result a tfi validation study from turkey showed that the rate of frailty was 636 40 the reason for relatively lower rates of frailty in our study compared to the turkey study may be associated with study participants being recruited from the community with a baseline age of ≥60 years whereas participants in turkey were older people admitted to a geriatric outpatient clinic with a relatively higher age these factors contribute to a higher frailty rate in turkey study our sample should not be considered representative of a general population of older people because study participants were recruited and examined from only one region in ethiopia thus a true prevalence of frailty can be either lower or higher and should not be determined on the basis of a validation study the finding of the current study demonstrated that the tfiam version demonstrated a very good level of reliability and an acceptable content validity this finding was consistent with studies conducted in other countries a study from the netherlands reported that 079 22 080 68 and a study from brazil showed a 078 46 cronbachs alphas values of reliability statistics for the tfi instrument across different studies it was found that the reliability coefficient of the tfi was acceptable 21 the reliability statistics for the polish version of the tfi were 072 41 074 23 and it was 066 44 for the italian version for frailty syndrome the german translation and psychometric testing also revealed a 067 44 reliability statistics of the tfi in comparison to studies conducted in various countries the current studys reliability statistics were higher the higher reliability of the tfiam in the current study could be attributed to the fact that the instrument was validated and piloted before being administered to any study participant using a culturally appropriate and contextually relevant processes these efforts contribute to a more consistent set of questions with a higher overall level of reliability the current study also demonstrated an acceptable reliability for the individual domains of the tfiam accordingly the finding showed that the physical psychological and social domains of the tfiam reliability was 075 070 and 068 respectively these findings showed a better reliability of the domains of the tfiam than studies conducted across other countries the study from the netherlands showed that the physical psychological and social domains of tfi were 074 061 and 051 68 respectively another instrument validation study with 479 communitydwelling people of 75 years and older in the netherlands showed that a 070 reliability statistic for the physical domain 063 for the psychologic domain and 034 for the social domain 22 a study from turkey also found that the reliability statistics for physical psychological and social domains were 0727 0675 and 0049 respectively 69 an instrument has face validity if it seems to identify what it is intended to measure and that it will work 70 the current study demonstrated that the face validity and scale agreement was excellent this finding is in line with a study conducted in the netherlands demonstrating that the face validity was satisfactory 22 a study in denmark however proposed that the tfi should be further tested in clinical practice 39 the content validity relates to whether a measurement instrument contains all essential components of the construct to be measured 71 the content validity of the tfiam demonstrated an acceptable value of icvi according to the current study the tfiam contains the important frailty items this finding is in line with reports from various studies which reported that the tfi contains the majority of important frailty items 2272 however it was noted that some important items were missed from a study conducted in denmark 73 the tfi has been validated in various populations and countries showing good reliability and validity 212574 the tfi assesses frailty across physical psychological and social domains 7576 this multidimensional approach to frailty contributes to clinical trials studying interventions that target different aspects of frailty the results of this study can contribute to the understanding of frailty across different cultural socioeconomic and lowincome settings this can assist to identify contextspecific determinants of frailty and inform culturally appropriate and contextually relevant interventions it can also contribute to developing local research insights related to ageing and frailty frailty research such as frailty tool validation in lowincome countries will contribute to strengthening the field of research within gerontology and geriatrics strengths and limitations this is the first effort to translate and culturally adapt the tfi for use within ssa and specifically from the ethiopian older persons perspective this instrument translation will allow for the assessment of frailty and evaluating interventions aimed at addressing frailty among older people in ethiopia importantly this instrument adaptation translation will contribute to researchers health care professionals and policy makers by serving as an early detection instrument this will also assist in determining possible interventions for improving the health status of older people in lowincome settings resulting the insufficient research outputs on frailty with no evidence of interventions to decrease frailty in ssa a research team aimed to investigate and measure the effectiveness of a nurseled intervention to decrease frailty status of ethiopian older people citation by authors to remain anonymised such efforts will contribute on how to reduce and possibly avert frailty in older people from ssa perspective however the results of the present study should be understood in the context of potential limitations other forms of reliability and validity tests need to be carried out the testretest reliability or the construct and predictive validity of the instrument were not assessed therefore our results indicate but do not prove that the translated version of the tfi is a valid and reliable measure of the common attributes of frailty future studies could examine testretest reliability construct and predictive value of the tfi with respect to other health outcomes including relocation to nursing homes higher rate of morbidity admission to hospital longer length of stay in hospital and increased rates of mortality moreover study participants were recruited from one region in ethiopia resulting in an unrepresentative result future research is needed to increase the sample size and confirm the generalisability in different amharic speaking regions conclusion the findings provide initial evidence that the tfiam version demonstrated a very good level of reliability and acceptable content validity for assessing frailty among communitydwelling older people from the ethiopian context the amharic adaptation of the tfi proved a useful easy to administer and fast for assessing frailty on communitydwelling older people nevertheless future research is needed to determine the efficacy of the tfiam for detecting frailty in communitydwelling ethiopian older people ageing research and the development of instruments to screen for agerelated problems will benefit policymakers in lowincome settings this will assist them to emphasise on the multidimensional needs of older people and develop strategies to strengthen the healthcare of older people ethics this study has been approved by the university of wollongong human research ethics committee approval number of 2022212 this study has also been approved by the institutional review board of college of medicine and health sciences bahir dar university approval number of 5632022 after the participants agreed to participate in this study a written informed consent was taken data analysis the collected data were checked for completeness and accuracy fully completed and cleaned data were entered into the ibm spss 260 for analyses categorical data were presented as numbers and percentages and continuous data as mean correlation of the scores of the three domains of the tfiam with the total score of tfiam was conducted using pearson correlation test a correlation coefficient of 01 to 03 03 to 05 and 05 was considered as weak moderate and strong correlations respectively 40 cronbachs alpha was used for the analysis of the internal consistency of the tfiam 61 percentage of agreement among raters were conducted to evaluate the face validity of the instrument the item level content validity index and the total content validity index average for the scale were undertaken using an excel spreadsheet to determine the validity of the instrument abbreviations icvi item level content validity index icmf integral conceptual model of frailty tfi tilburg frailty indicator tfiam tilburg frailty indicator amharic version ssa sub saharan africa scviave total content validity index average for the scale uow university of wollongong disclosure the authors declare that there is no conflicts of interest in this work

background frailty is a global health problem including in african countries despite this no reliable or valid frailty instruments incorporate any african language and no research exists to crossculturally adapt and test the validity and reliability of instruments commonly used in other countries for use within african countries the tilburg frailty indicator tfi is a reliable and validated instrument with the potential to be relevant for older populations living in africa this study aimed to develop the tfi amharic tfiam version for use within ethiopia methods this study employed psychometric testing and the evaluation of a translated and adapted instrument the original english language version of the tfi was translated and culturally adapted into amharic using the world health organization process of translation and adaptation of an instrument a convenience sample of ninetysix communitydwelling older people 60 years and over was recruited cronbachs alpha was used for the analysis of the internal consistency of the tfi amharic tfiam version using ibm spss 260 ibm corp armonk ny usa face and content validities of the tfiam were determinedthe tfiam total mean score was 576 ±289 the internal consistency of the tfiam was very good with an overall cronbach alpha value of 082 the physical domain showed the highest reliability with a 075 cronbachs alpha value while the social domain was the lowest with a 068 cronbachs alpha value the cronbachs alpha reliability coefficients of the instrument ranged from 068 to 075 the item content validity index value ranged from 083 to 10 and the total content validity index average for the instrument was 091the tfiam is reliable valid and reproducible for the assessment of frailty among communitydwelling older populations in ethiopia tfiam proved an easytoadminister applicable and fast instrument for assessing frailty in communitydwelling older populations

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the gaza strip 4 living in the gaza strip in the occupied palestinian territories means living in a land full of barriers and obstacles even for activities that we normally give for granted this land has been shaped by decades of occupation blockade and war in 1967 it was invaded and occupied by israel since 2007 after hamas won the elections gaza is isolated from the west bank and the rest of the world and is suffering a land air and sea blockade in the last 15 years gaza was subjected to four wars with civilian infrastructures targeted in the agricultural energy and water fields and this situation is impacting everyday life 85 of gazans depend on food aid the population is living a humanitarian crisis and the blockade is restricting the possibility to rebuild what conflict is destroying in this context of dedevelopment where it seems impossible to see human potential and any change mental and physical wellbeing of palestinians is aggravating restrictions on mobility unemployment poverty crisis in education health safety made gaza become an unliveable place after the 20082009 war a research in the field of education found significant psychosocial problems affecting students learning and the increase of drug abuse due to this prolonged conflict longterm impacts on child development cause learning difficulties making it more difficult to complete studies and achieve higher education these difficulties are more evident in fragile groups people with disabilities represent one of the most vulnerable groups within the gaza strip being the 26 of population they are forced to face extreme difficulties in daily life excluded from the enjoyment of their rights and subject to discrimination this situation is even more serious for women with disabilities who suffer double discrimination being female and being disabled in gaza it emerges that the main obstacles to the recognition of the rights of pwd and their full social inclusion are linked to three interconnected factors nonautonomy nonaccess to socioeconomic empowerment opportunities stigma of the community nonautonomy is due to the poor accessibility of places and the lack of appropriate aids lack of empowerment is linked to difficulties in accessing education and lack of job opportunities finally social stigma affects both the selfesteem of pwd and their individual and social empowerment process the ministry of education and higher education in palestine has developed policies addressed to the development of educational and social practices based on inclusion and implemented in the national school system according to unicef 231 of pwd in palestine have serious difficulties accessing education due to social discrimination and about 43 of children with disabilities aged 617 years are not enrolled in education in the gaza strip here around 452 of children with disabilities aged 69 years are out of school compared to 09 of their peers without disabilities gender inequalities are significant and show that 366 of 1015 years old girls with disabilities are out of school compared to 263 of boys with disabilities in the same agegroup the ican project it is in this context of deprivation and immobility that the ican independence capability autonomy inclusion project was born in with the primary purpose of contrasting this sense of dedevelopment separation and closure responding with inclusive education strategies the three years ican project6 was founded by aics and coordinated by the italian ngo educaid its main objective was to promote the full inclusion of people with disabilities in particular women and the families of students attending 15 selected schools within the gaza territory the project consisted of these following two main actions • establishing a holistic and innovative centre to support teachers educators youth workers and families in the promotion of initiatives directed at building inclusive community educational contexts • promoting research and experimentation in the schools involved more in detail the project launched an exploratory survey aimed to detect the schools level of inclusion followed by experimentation of the index for inclusion and empowerment this tool has been coconstructed formalized and tested starting from the original index for inclusion by booth and ainscow in the framework of a previous project carried out in west banks palestinian schools the approach was centred on bottomup strategies in the construction of the tool and in the actions implemented with a cooperative and constructivist methodology necessary to develop a community of teachers able to collaborate reflect and plan together also after the project itself the iie is functional to the design and selfevaluation of the quality of inclusion processes in communities and schools and it integrates the perspective of inclusion and empowerment as emancipatory process in both an individual and social dimension within the ican project experimentation required training for teachers about the use of the iie for planning inclusive school policies and identifying educational priorities not only in schools but also in the community the role of the university of bologna department of education studies was to coordinate the training actions targeted to the holistic centres staff and to consult in the research and monitoring actions regarding the use of the iie in schools and communities as the pandemic situation started in early 2020 during the second half of the research the situation in schools was more complex teachers had to manage remote teaching and being able to communicate effectively with families and parents had to fully support their children in home teaching and maintain open communication with teachers and other parents for this reason the project addressed these new challenges • a qualitative inquiry on the impact of lockdown and the forced use of technology in communication between teachers and families • the proposal of guidelines for technologymediated schoolfamily communication researchs goal the research aimed to investigate the schoolfamily communication practices mediated by technology during covid19s lockdown in the gaza stripes schools the need for investigating this dynamic came from the local ministry of education and the ican projects leader the italian ngo educaid during the pandemic all the schools of the palestinian territories and gazas stripe found themselves in a very complicated situation not only the problem of their students scolarisation needed to be addressed but also the problem of keeping an open dialogue and contact with their students families methodology the exploratoryqualitativebased research described in this contribution saw the involvement of 15 middle schools located in gazas stripe eight unrwa schools and seven public schools run by the moehe three focus groups have been conducted one with six teachers from first to fourth grade one with five teachers from fifth and sixth grade and one with ten parents having children attending different schools the focus group were conducted online with people selected voluntarily in arabic and lasted 60 minutes to facilitate the process of data analysis and to support the interviewer the researchers structured the focus groups scripts in a list of questions that served as guidance for conducting the discussion questions for teachers focus group were articulated in the following six sections instructional design during the pandemic have you managed to keep organising a regular meeting with the rest of your colleagues distance learning during the pandemic have you changed and adapted your way of running and managing your lessons how which major challenges have you faced which aspects of your past practices have you maintained because successful distance evaluation during the pandemic have you changed and adapted your way of evaluating your students how which major challenges have you faced digital competences were your digital skills sufficient to manage the emergency and distance learning moment schoolfamily communication during due to space reasons the present paper mainly presents the results more closely connected to the communication dynamics occurring between all stakeholders of school what emerged from teachers especially during the pandemic teachers found it difficult to maintain regular meetings with their colleagues due to the following aspects • teachers lack of digital competence put some of the teachers in the condition of not being able to communicate properly in a short time with the others • teachers lack of adequate digital tools caused lots of technical problems teachers reported not only issues in terms of possessingnot possessing adequate digital tools but also a proper internet connection • lack of official digital communication platforms both teachers from first to fourth grade and from fifth to sixth grade used nonofficial platforms to communicate with their colleagues whatsapp and facebook have been largely used for maintaining an exchange with the other teachers and to reach some families • difficulties in the communication dynamics mediated by technology maintaining a relationship was harder because the teachers were used to meeting and interacting without the mediation of a digital tool • psychological stress many teachers stated that during the pandemic they were suffering from their working conditions more hours spent sitting in front of a screen less free time because of the need to adapt their educational strategies to the online interaction and the absence of breaks between one lesson and the other are among the most relevant motivations which teachers brought • workload increase another critical aspect raised by the teachers during the focus group was the increase in their workload managing the transition between a school anchored to the present towards a digitalmediated one meant a lot of work in preparing all the lessons revising all the activities in managing the technical issues and rethinking the evaluation strategies regarding schoolfamily communication dynamics teachers made an important remark none of their schools settled an official tool for schoolfamily communication this forced them to communicate with their students families through nonofficial digital tools such as zoom facebook messenger whatsapp or ims among the most relevant difficulties faced during the pandemic concerning the schoolfamily communication dynamics teachers reported the following • technical issues internet cuts or electricity blackouts represented a big obstacle in interacting with the families this in gaza strip territories was not only a huge problem during the pandemic but also in every days life of the people who are forced to live in a constant reclusionlike situation • lack of adequate digital devices from teachers families and students the economic conditions of many families living in the gaza strip do not allow the possession of a proper device for all the members of the family and this may cause the malfunction of some of the devices used by the students or by the parents • parents lack of support in terms of schoolfamily alliance the families in difficult conditions were the hardest ones to reach and collaborate with during lockdown this did emphasise the distance between these families and the school even more • parents low levels of digital competence teachers reported that parents do not have enough confidence in using a digital device and this hindered their contact with them during the pandemic • privacy issues many parents have been contacting privately teachers on their mobile phones during inappropriate times what emerged from parents parents reported that the main difficulties related to this aspect are the following • lack of devices parents stated that many palestinians cannot afford to have a device for every member of the family this affects negatively on the possibility of getting connected and properly following the schools online activities it also affects the relationship dynamics within the members of the family by opening ground for potential conflicts another problem raised is related to the space available on the devices especially if multiple people share these devices this means less space to store apps videos photos and learning materials • technical problems according to the parents that participate in the focus groups gaza strips territory is plagued by a very lowquality of internet connection along with frequent electricity cuts this caused many problems in granting proper participation in online schools activities • lack of an official schoolfamily communication platform another concern expressed by parents is the fact that the schools do not provide an official space to communicate with teachers some teachers used to send the homework via email some via whatsapp and some other with other social media and this created a lot of confusion forcing the parents to monitor multiple platforms • psychological stress parents denounced a state of the psychological pressure of being home and following school tasks and home family management for instance when working on producing videos with their children many parents reported that the noise in the house was a problem another problem raised is about finding the proper spaces many parents reported the lack of privacy for the child and contextually issues in managing the rest of the children • lack of digital competence parents reported that at the beginning of the covid19 pandemic their digital skills were far from being sufficient to face the situation from the focus group emerged that thanks to the help of some teachers and their continuous efforts in providing support many mothers could develop new competencies in managing digital tools regarding the communication dynamics between families and other families a large part of the parents reported that they felt the need for a more open and continuous communication with their peers the motivations brought were mainly the following 1 parents feel uncomfortable explaining to their children the materials that teachers send and therefore they looked for support from other parents 2 having the support of other parents point of view on how they were dealing with all difficulties helped them a lot about the communication dynamics between families and teachers parents reported that not all the teachers were available and easy to reach but that in general they could communicate with them sufficiently some parents complained about the fact that teachers could not always reply on time to their request for help in this regard 1 st to 4 th grades teachers were much more available and reachable compared to 5 th to 6 th grades ones the guidelines thanks to the focus group the researchers working together with the gazas team of educaid teachers and parents involved in the research produced guidelines for an inclusive schoolfamily communication and for facing distance learning in emergencies these guidelines are divided into two sections one dedicated to teachers and the other to parents the teachers section of the guidelines is structured into five different areas of interest • instructional design this area offers insights for improving the collaboration among colleagues to better organise the way teachers plan their educational interventions • distance learning this area contains advice to improve the management of distance learning situations • distance evaluation this areas aims is to provide teachers more tools to improve the way they evaluate their students • schoolfamily communication this area focuses on the possible strategies that teachers may use to communicate inclusively and effectively with their students families • communication with other teachers this areas main focus is providing teachers with strategies and tools that they can use to communicate inclusively and effectively with their colleagues the section dedicated to the parents is articulated into four areas of interest • supporting distance learning this areas aim is to provide parents guidance in how they can support their children in participating to online distance schools initiatives • digital technologies this area focuses on the management of the digital tools within the family providing hints on how to find a balance in the economy of the timings and the spaces to use those devices • schoolfamily communication this area provides insights and support to parents in how they communicate more effectively with their childrens teachers • communication between parents this area contains guidelines and suggestions dedicated to parents about how to communicate more efficiently and inclusively with other parents conclusions the guidelines produced during the project although developed in the emergency context of the pandemic highlighted new ways in which schools can communicate with families more inclusively and effectively beyond the lockdown imposed by the covid in fact the guidelines proved to be a fundamental tool for reflecting on communication dynamics between school and family and for proposing new ways of connecting and shape relationships the palestinian context particularly in gaza strip which is always at risk of closures and suspensions of educational services due to the conflict needs to question what the inclusive strategies are to keep communication and collaboration between school and family active and to guarantee the right to education in this sense the guidelines offered a space to reflect on teachers working conditions and on families situations raising few key elements that should be addressed to create a more inclusive schoolfamily communication • the importance of maintaining a contact and to make sure that no one is excluded • the relevance of activating innovative learning strategies that are studentcentered and that promote equal participation of the learners • the value of managing schoolfamily communications time more effectively and in a way that it is more respectful to the privacy of the actors involved • the importance of creating meaningful schoolfamily alliances which go beyond acknowledging the importance of parents involvement in the educational processes in particular the issue of schoolfamily alliances represented an important topic in the gazan and pandemic context teachers realized how this alliance is a dynamic process that must be continuously built and rebuilt requiring continuous adjustments and redefinitions over time it is more difficult than a simple interaction as it involves the understanding and acceptance of points of view sometimes opposites in a context where schools are subjected to closures because of conflicts itis necessary to develop mutual interdependence to work together to achieve common educational goals teachers and families should share a common vision of the school the school should inform on values didactic objectives evaluation methods tools and support families in defining their active role and tasks in the educational process while families should motivate and mediate supporting those parents more in need communication between school and family is a nerve center to the achievement of educational success and to the full enhancement of educational interventions from this derives the possibility of thinking of the family not only as a source of help and support to the school but also as an actor who can contribute to qualify the school enterprise sharing ones wealth of experiences and reflections 7 only when this communication is clear and bidirectional when it involves all actors it is possible to develop a sense of belonging to a community to avoid clashes between teachers and families therefore seeing others as a resource not as an obstacle

ican independence capability autonomy inclusion was an international cooperation project run in 20182021 which involved 15 selected gaza strips schools whose objective was to promote the full inclusion of people with disabilities the project was articulated in two main actions the first was the establishment of an holistic and innovative centre created to support educators and families in the promotion of initiatives directed at building inclusive communities the second was a qualitative research which explored the implications that the lockdown and the forced transition towards technologymediated communication had on schoolfamily relationship

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introduction conflicts wars disasters triggered by natural hazards and climate change may threaten all generations causing many people to migrate from treacherous vulnerable and stressful conditions to destination countries 12 refugees might suffer exploitation prejudice and violence during their journey and stay in host countries which may negatively affect their health 3 due to its geographical location ethnic structure and internal unrest afghanistan continuously generates immigrants and afghans have been migrating to neighbouring countries such as iran for centuries 45 according to the united nations high commissioner for refugees the islamic republic of iran hosts one of the largest and most protracted urban refugee populations worldwide with approximately 3 million afghans living in the country 6 the challenges of afghan refugees in iran include a low level of education low health literacy a lack of insurance low access to healthcare services and high medical expenses 7 in addition evidence showed that the prevalence of communicable and noncommunicable disorders psychological problems and mental disorders among afghan refugees in iran is higher than in the iranian population 78 the covid19 pandemic has created significant challenges in 2020 in the world and iran studies have reported psychological problems such as anxiety depression and posttraumatic stress disorder refugees may be significantly affected by covid19 as the pandemic reminds them of their past conflicts and traumas of persecution 910 results of scientific research have shown that several factors are associated with the prevalence and spread of covid19 disease including age very high contact poor general health nutritional status underlying chronic conditions 1112 as well as psychological problems such as depression anxiety 13 most refugees may live in crowded living conditions making it difficult to control the covid19 outbreaks in these groups 14 15 16 studies have revealed that the health needs of refugees have been largely neglected in global healthcare responses 17 health inequalities have increased and access to health services has often significantly been restricted among afghan migrants during the pandemic 18 quality of life is defined as an individual perception of their position in life in the context of the culture and value systems in which they live and concerning their goals expectations standards and concerns 19 a wide range of factors was found to have significant associations with qol including mental health higher age adverse life events postmigration living problems socioeconomic living conditions and socioreligious aspects 2021 in addition studies have indicated that refugees qol is highly influenced by the conditions they live in postmigration and social determinants of health mental health mediates these effects 2223 to help vulnerable groups such as refugees during the covid19 pandemic identifying the qol and its associated factors will help inform governments on how to address the challenges of health emergencies better however to our best knowledge there is no research to examine social determinants of health factors including socioeconomic status access to healthcare services and mental health in the quality of life together in afghan refugees during different phases of the covid19 pandemic such as response and recovery phases therefore considering the challenges of the covid19 pandemic and the critical role of social determinants of health we examined the effect of social determinants of health on the quality of life among afghan refugees in iran during the covid19 pandemic materials and methods design and participants this study crosssectional study was conducted on 300 afghan refugees and migrants in alborz province iran from february to may 2022 by using convenience sampling the inclusion criteria were age over 15 years afghan nationals who have lived in iran for at least one year ability to answer questions and willingness to participate in the study exclusion criteria were mental retardation and dementiaalzheimers disease the samples were selected from the general population by using convenience sampling after selecting the subjects trained experts collected data through interviews and questionnaires this research was performed by the latest version of the declaration of helsinki and with the approval of the research ethics committee of alborz university of medical sciences informed consent was obtained from all participants after being informed of the nature of the research data collection data were completed using a questionnaire including 1 a sociodemographic checklist included age gender education level marital status occupation income number of family members the history of underlying chronic disease history of covid19 disease and the frequency of infection with covid19 2 socioeconomic status scale ses consisted of 6 questions including education income economic class and housing status which are scored based on a likert scale from 1 to 5 and a total score ranging from 6 to 30 validity and reliability have been performed in iran 24 3 the world health organizations quality of life bref 25 was used to determine the quality of life in participants the questionnaire consists of 26 selfreport questions measured on a 5point likert scale the first two items were overall quality of life and overall health status the remaining 24 items encompass four domains physical health psychological health social relationships and environmental according to the manual scores were transferred to a scale from zero to 100 we considered the total qol score for path analysis in which a higher score indicates a better quality of life the questionnaire has been validated in an adult iranian population 26 4 depression anxiety and stress scale21 items questionnaire 27 we used the persian version of dass21 to assess the depression anxiety and stress which has reliability and validity 28 the dass21 is a selfreport questionnaire that includes 21 items seven items for each category patients rated each item on a scale from 0 to 3 total scores were calculated by summing the item scores in each subscale therefore total scores for the dass21 scale range from 0 to 63 we considered the total dass21 score for path analysis 5 the covid19 posttraumatic stress disorder checklist the ptsd 8item inventory 29 is derived from the htq part iv 30 and is a short ptsd scale that includes eight items measuring posttraumatic stress symptoms each item is presented on a 4point likert scale ptsd8 consists of three clusters including intrusion avoidance and hypervigilance ptsd and subscales score was calculated by summing the scores of the questions possible ptsd is defined by at least 1 item within each ptsd symptom cluster with a score of 3 or higher ptsd8 has good psychometric properties the validity and reliability of the ptsd 8item inventory have been confirmed by hansen et al 29 the questionnaire has also been validated in the iranian population during the covid19 pandemic 31 6 access to healthcare services this checklist includes three questions about the distance from home to healthcare centres travel costs to healthcare centres and waiting time to receive services ranging from 3 to 12 the lower the score shows the better the access to health services selfrated health includes one question about peoples perceptions of their health ranging from 1 to 4 research variables variables used in the path analysis included age the number of family members socioeconomic status number of covid19 conflicts access to medical services selfrated health dass ptsd and quality of life statistical analysis all analyses were performed using spss 220 first the study populations demographic characteristics were described using descriptive statistics mean standard deviation for continuous variables and frequency for categorical variables next the pearson correlation coefficient was calculated to evaluate the relationships among the variables then path analysis was applied to evaluate the relationships among the research variables mentioned above path analysis is an extension of the regression model which assesses the effects of a set of variables acting on a dependent variable via multiple causal pathways 32 the model fit is acceptable with a cutoff value of 09 for the comparative fit index goodness of fit index and bentlerbonett normed fit index as well as a cutoff value of 005 for the root mean squared error of approximation 33 according to previous studies 10 2023 34 35 we developed a theoretical conceptual framework using path analysis results a total of 316 respondents completed our questionnaire in the end 16 were excluded because they were below 15 years or had incomplete questionnaires of the 300 participants in the study 643 were male the mean ± sd age of people was 2929 ± 964 the most educational level was elementary and illiterate 64 were workers in addition 60 participants had at least one underlying disease the most frequent disease was diabetes the demographic characteristics of patients are shown in table 1 the mean ± sd of ses covidptsd and dass were 943 ± 35 1475 ± 37 and 2067 ± 99 respectively as well as the mean ± sd scores of qol subscales including physical health psychological health social relationships and environmental domain were 5162 ± 1364 4614 ± 1814 4805 ± 2276 and 3960 ± 1466 respectively before path analysis bivariate analysis was used to assess the correlations between variables qol was directly correlated with the number of family members ses selfrated health and access to medical services and inversely correlated with the number of covid19 conflicts ptsd and dass the relationship between qol and social determinants of health in afghan refugees was studied based on the path analysis model figure 2 shows the full empirical path model between the qol and social determinants of health according to tvalue tvalue 196 is significant and is shown in black colour based on the results of the path analysis among the variables that had a causal and significant relationship with the qol from only one path selfrated health had the most positive relationship and the dass score had the most negative relationship with the qol in other words an increase in the srh score increases the quality of life score and an increase in the dass score decreases the quality of life score access to medical services was the only variable that indirectly had a positive causal relationship with qol so an increase in the ams score increases the quality of life score the number of family members directly had a positive causal relationship with qol among the variables that had a significant causal relationship with qol from both paths socioeconomic status had the most positive relationship and the number of covid19 conflicts had the most negative relationship in other words an increase in socioeconomic status increases the quality of life score and an increase in the number of covid19 conflicts decreases the quality of life score figure 3 shows the full empirical path model between 4 discussion in this study we evaluated the association between quality of life with social determinants of health including sociodemographic factors ses das ptsd access to medical services selfrated health and the number of covid19 conflicts among afghan refugees and migrants during the covid19 pandemic trough path analysis we observed dass score had a negative relationship with quality of life only through the direct path these findings extend to studies 213436 confirming that those affected by anxiety and depression had unfavourable qol in line with our study a study in turkey investigated sociodemographic factors and the mental health of women refugees on quality of life and found that mental health mediates these effects 23 people with mental problems experience a poor quality of life due to distress hopelessness and demoralization lack of control choice and autonomy low selfesteem and confidence feeling of not being part of society and reduced activity 37 the current studys findings showed that selfrated health had a positive relationship with quality of life only through a direct path consistent with the study of pitkala et al 38 physical health is essential for mental health because physical illness may cause anxiety and isolation 39 in this study access to medical services was the only variable that indirectly had a positive causal relationship with quality of life consistent with another study 3940 that showed relationships between access to health services and mental health and quality of life the general quality of life however includes an individuals evaluation of all aspects of life including factors such as the safety of the environment in which they live whether they have access to health care and social services and their current spiritual status 41 socioeconomic status positively correlated with the quality of life on both paths in line with our survey other studies have shown that high levels of psychological distress were most common among individuals with lower levels of ses 3942 also a study showed an indirect effect of ses on the quality of life by path analysis 43 we observed that number of covid19 conflicts negatively affected the quality of life from both paths a study on refugees in bangladesh also showed a negative impact of the covid19 pandemic on their quality of life 44 the mean ptsd of afghan refugees in our study was higher than a study of iranian pupations 45 which may be because of a higher level of stress anxiety depression and other immigration problems in afghan refugees a qualitative study in iran illustrated that afghan refugees especially women are very vulnerable to covid19 the reasons include their little knowledge and information about covid19 limited access to information resources family challenges socioeconomic challenges health issues and problems after the death of a covid19 patient 46 in our study the number of family members had a positive causal relationship with quality of life when family members are together and have a good relationship they live better together which can help increase their quality of life therefore it can be expected that family cohesion is the determining factor in peoples quality of life during the pandemic period 47 the findings of our study showed that negative emotional states of depression anxiety and stress are one of the most critical factors affecting the quality of life of afghan refugees psychosocial support during the pandemic is one of the things emphasized by humanitarian organizations 48 in addition the intersectionality of social determinants of health such as age gender ethnicity income status etc increases the need for these supports 49 according to a report by the womens commission for refugee women and children too often invisible too often forgotten and too often overlooked refugees with disabilities are among the most isolated socially excluded and marginalized of all displaced populations 50 intersectionality in the group of refugees makes them more vulnerable and needs psychosocial support limitation all the questionnaires used in the current research were selfassessments therefore selfreport bias due to personal attitudes was inevitable conclusion we provided an empirical model that illustrates the relationships between quality of life and social determinants of health including sociodemographic factors ses das ptsd access to medical services selfrated health and the number of covid19 conflicts among afghan refugees and migrants variables that affect qol only through a direct path included mental disorders which had a negative relationship selfrated health and the number of family members who had a positive relationship with quality of life socioeconomic status had the most positive and the number of covid19 conflicts had the most negative relationship with the quality of life from both direct and indirect paths access to medical services was the only variable that indirectly had a positive causal relationship with quality of life negative emotional states of das as a mediator play an essential role in the quality of life and other variables so public health policymakers should pay more attention to the mental health of afghan refugees to improve their quality of life competing interests there are no conflicts of interest

background the covid19 pandemic has created significant challenges in 2020 in the world and iran to help vulnerable groups such as refugees during the response and recovery phases of the covid19 pandemic identifying the quality of life qol and its associated factors is helpful considering that research in this field is limited this study evaluated the effect of social determinants of health on the quality of life among afghan refugees in iran during the covid19 pandemicwe conducted a crosssectional study on 300 afghan refugees and migrants in alborz province iran from february to may 2022 using convenience sampling data were completed using the socioeconomic status scale ses world health organizations quality of life bref whoqol depression anxiety and stress scale21 items dass21 and covid19 posttraumatic stress disorder checklist covidptsd in addition path analysis was applied to evaluate the relationships among the research variables with quality of life results 643 of the study participants were male with a mean of 2929 ± 964 years the path analysis showed that ses had the most positive relationship b 266 and the number of covid19 cases had the most negative relationship b 169 with the quality of life from both paths the selfrated health had the most positive relationship b 25 and the dass score had the most negative relationship b 2 with the quality of life through only one path access to medical services was the only variable that indirectly had a positive causal relationship with qol b 044 we provided an empirical model that illustrates the relationships between quality of life and social determinants of health among afghan refugees and migrants during the covid19 pandemic the negative emotional states of depression anxiety and stress das as a mediator play an essential role in the quality of life and other variables keywords covid19 dass21 posttraumatic stress symptoms quality of life social determinants of health selfrated health

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background nutrition has a big impact on peoples health and is closely tied to social and cognitive development particularly in childrens formative days 12 children cannot receive their complete recommended ageappropriate nutrition in environments with low income and social resources 1 in children suboptimal infant and young child feeding practices remain serious public health problems 3 to overcome these concerns complementary feeding should be started in children who are 6 months of age and above 2 complementary feeding is the introduction of liquids and other foods along with breast milk for 623 months age children 4 world health organization defines minimum acceptable diet practices for 623 months age children as a combination of both minimum meal frequency and minimum dietary diversity in both breastfeeding and nonbreastfeeding children 56 in many countries less than onequarter of children are reported not getting the nutrition they need to grow well particularly in the crucial first 1000 days 78 child undernutrition is a major public health problem in many resourcepoor communities in the world 3 among children aged 6 to 23 months from low socioeconomic status only one in five can feed the minimum recommended diverse diet which is one component of mad 8 the first 2 years of age of the childs life provide an opportunity to ensure the growth development and survival of the child through optimum infant and young child feeding practices 4 therefore inappropriate iycf practices during this period result in significant threats to child health by compromised educational achievement impaired cognitive development and low economic productivity which become difficult to reverse later in life 4910 inappropriate feeding practices during the first 2 years of life are a cause for more than twothirds of malnutritionrelated child deaths 11 malnutrition is linked to just half of all deaths of under five children in each year 48 optimal complementary feeding practices prevent approximately onethird of child mortality 12 research has shown that in subsaharan africa children lost up to 25 years of schooling if there was a famine while they were in utero and during their childhood 8 even though the minimum acceptable diet problem has multiple causes it is widely agreed that inadequate iycf due to socioeconomic inequalities is one of the most immediate determinants 113 socioeconomic inequalities in child nutrition are a concern for health differences since it is resulting from factors considered to be both avoidable and unfair 14 the global burden of childhood undernutrition is concentrated in lowincome and lowermiddleincome countries and becomes a vicious cycle with their economic status 15 in countries with low socioeconomic status with inadequate food and resources children can not have full growth and developmental possibilities 1 subsaharan africa is loaded with half children living in extreme poverty among 385 million around the world whereas over a third live in south asia 8 according to the global nutrition report in 2020 there were inequalities in dietary diversity meal frequency and minimum acceptable diet children from the richest households do far better as do a more educated mother or those who live in urban areas 1516 there were an 115 wealth gap 49 location gap and a 77 education gap of minimum acceptable diet intake 16 a lot of interventions have been taken to overcome these problems 1617 the united nations secretarygeneral launched the zero hunger challenge in children by fulfilling objectives such as 100 access to adequate food all year round zero stunted children under 2 years and sustainability of all food systems 17 world health organization set as strategies for complementary feeding practice by using multiple micronutrient powders for home fortification of foods and vitamin a for children 623 months of age 18 despite these lots of interventions that have been taken the minimum acceptable diet usage is still low 8 therefore identifying and reducing the avoidable socioeconomic inequalities of minimum acceptable diet intake and its contributing factors are an important issue in improving the overall health and wellbeing of the child 14 there have been studies reporting the burden and determining factors of childhood mad usage in different program that endorses women empowerment such as income generation cash assistance for mothers who have under 2 years of children and women employment using affirmative actions and nutrition education such as media campaigns and promoting breast feedings longterm plans are also needed for those ssa countries with lower income status through programs to enhance their countrys economy to the middle and higher economic level and to improve the wealth index of individual households to narrow the poorrich gap in the minimum acceptable diet intake keywords minimum acceptable diet socioeconomic inequalities and subsaharan african countries of subsaharan africa but those studies were used regionally varied local food items to assess mad intake among children which makes it difficult to make pooled estimates and regional comparisons however this study used the most recent standard dhs dataset which was collected in a similar design and standardized parameters makes easy to have pooled prevalence of mad intake among children therefore this study aimed to assess the pooled prevalence the level of socioeconomic inequalities of mad intake and contributor factors for the inequalities among children aged 623 months in ssa countries it will be the crucial point for policymakers to know child nutrition status in the region and draft child nutrition policy and take actions based on the evidence methods study design setting and period the data source for this study was the recent standard dhs data of subsaharan african countries conducted within 10 years which was a crossectional study conducted every fiveyear interval to generate updated health and healthrelated indicators the subsaharan is the area in the continent of africa that lies south of the sahara and consists of four geographically distinct regions namely eastern africa central africa western africa and southern africa 19 but economically according to the 2019 world bank list of economies classification categorized as low income lower middle income and uppermiddleincome country 20 together they have a total population of 11 billion inhabitants 21 the datasets are publicly available from the dhs website dhspr ogram com 19 dhs collects data that are comparable across countries the surveys are nationally representative of each country and populationbased with large sample sizes all surveys use a multistage cluster sampling method 22 population the source population was all children aged 623 months preceding 5 years of the survey period across 33 subsaharan african countries whereas the study population was children aged 623 months preceding 5 years the survey period in the selected enumeration areas and the mother or the caregiver was interviewed for the survey in each country mothers who had more than one child within the 2 years preceding the survey were asked questions about the most recent child 23 sampling procedures and sample size a total of 47 countries are located in subsaharan africa of these countries only 41 countries had demographic and health survey report from these five countries that did not have a survey report after the 20102011 survey year were excluded these countries are central africa republic eswatini sao tome principe madagascar and sudan as well as three subsaharan countries were excluded due to the dataset not being publicly available then after excluding countries that had no dhs report after 2010 and countries where the dhs dataset was not publicly available a total of 33 countries were included in this study typically dhs samples are stratified by geographic region and by urbanrural areas within each region dhs sample designs are usually twostage probability samples drawn from an existing sample frame enumeration areas were the sampling units for the first stage of sampling in selected eas households comprise the second stage of sampling following the listing of the households a fixed number of households is selected by equal probability systematic sampling in the selected cluster 22 the detailed sampling procedure was available in each dhs reports from the measure dhs website 22 weighted values were used to restore the representativeness of the sample data and were calculated from childrens records or kids records dhs datasets finally a total weighted sample of 78 542 children in the age category of 623 months from all 33 countries were included in this study table 1 study variables dependent variables the outcome variable of this study was taking minimum acceptable diet of children 623 months which is combined from children who had minimum meal frequency and minimum dietary diversity in both breastfeeding and nonbreastfeeding children during the survey their mother was asked questions about the types and frequency of food the child had consumed during the day or night before the interview 22 if a child is taken four out of seven food groups fed during the day or night preceding the survey the following food items are considered as getting minimum dietary diversity these are grains roots and tubers legumes and nuts dairy products flesh foods eggs vitamin arich fruits and vegetables and other fruits and vegetables whereas minimum meal frequency is the provision of two or more feedings of solid semisolid or soft food for 68 months three or more feedings for 923 months breastfeed and four times for nonbreastfed children the data of the above variables were collected similarly across all ssa countries 622 since minimum meal frequency has a different cutoff value for different age groups and breastfed and nonbreast feed children so as the overall meal frequency computed after computing for each group independent variables sociodemographic factors such as marital status and household family size socioeconomic factors such as educational attainment of women occupation of women and country income status health behavior factors such as media exposure and breastfeeding status and geographical factors such as place of residence and subregion in ssa are all taken into account the countries income status was categorized as low income lower middle income and uppermiddleincome country based on the world bank list of economies classification since 2019 20 world bank calculated country income based on gross national income per capita which categorized as low income 1025 or less lower middle income 10263995 upper middle income 399612375and high income 12375 or more 20 data processing and analysis this study was performed based on the dhs data obtained from the official dhs measure website measu redhs comafter permission has been obtained via an online request by specifying my objectives data from the dhs dataset were downloaded standard dhs data in stata format then cleaned integrated transformed and append to produce favorable variables for the analysis microsoft excel and stata 16 software were used to generate both descriptive and analytic statistics of the appended 33 countries data to describe variables in the study using statistical measurements the variance inflation factor was used to detect multicollinearity and all variables had vif values less than 10 and the mean vif value of the final model was 157 the pooled estimate of mad intake among children in subsaharan africa and subregions was estimated using the metan stata command model building concentration curve and index the concentration index and concentration graph approach are used to examine socioeconomic inequalities in health outcomes 2425 the concentration curve is used to identify whether socioeconomic inequality in some health variables exists and whether it is more pronounced at one point it displays the share of health accounted for by cumulative proportions of individuals in the population ranked from the poorest to the richest 2526 the two key variables underlying the concentration curve are the health variable and the distribution of the subject of interest against the distribution of the variable capturing living standards 27 the concentration curve plots the cumulative percentage of mad usage against the cumulative percentage of children 623 months ranked by living standards beginning with the poorest and ending with the richest households 27 a 45 0 line running from the bottom lefthand corner to the top righthand corner concentration curve would be indicated the absence of inequity furthermore the concentration curve lying above the equality line indicated that mad intake is disproportionately concentrated between poor and whereas below the equality line indicated concentrated on rich 28 to quantify and compare the degree of socioeconomic related inequality in mad intake concentration index is used 2629 and it is twice the area between the concentration curve and the line of equity with the range of 1 to 1 the sign indicates the direction of the relationship between mad intake and the distribution of living standards 2527 where hi is the health outcome μ is the mean of hi and n is the number of people ri represents the fractional rank of individual i in the living standards distribution used with i taking the value of 1 for the poorest and the value of n for the richest 272930 as a result c 0 showed that mad intake was disproportionately concentrated on the rich and ci 0 revealed that the mad intake is disproportionately concentrated on the poor 2728 whereas c 0 indicated that the distribution is proportionate accordingly c 1 showed that the richest person had children taken mad whereas c 1 indicated that the poorest person had all of the children taken mad 2730 but the outcome variable in the present study is binary the bounds of c depend on the mean of the outcome variable and do not vary between 1 and 1 thus the bounds of c vary between μ1 and 1μ and the interval shrink when the mean increases as a correction the present study applied the wag staff normalization to calculate the concentration index by dividing c by 1 minus the mean 2730 c 2 nµ n i1 hiri 1 wag staff decomposition analysis wag stafftype decomposition analysis was performed for those variables that were screened statistical significance based on multilevel analysis and clinical significance after the concentration index and curve were assessed and showed incomerelated inequality to the magnitude of mad usage the wag stafftype decomposition analysis quantifies the degree of incomerelated inequalities of the minimum acceptable diet intake and explains the contribution of each factor to the observed inequality 31 concentration index decomposed based on regression analysis of the relationship between an outcome variable and a set of determinants the overall concentration index can be decomposed into k social determinant contributions in which each social determinants contribution is obtained by multiplying the sensitivity of the outcome related to that determinant and the degree of incomerelated inequality in that factor 2732 based on a linear additive regression model the concentration index for minimum acceptable diet intake can be expressed as follows where μ is the mean of y x ̅ k is the mean of xu ck is the concentration index of xk and gcε is the generalized concentration index for the error term the overall concentration index of mad intake includes the explained part which is the sum of the contributions of k determinants and the unexplained part based on the wag staff normalization the normalized decomposition of the concentration index obtained by dividing the concentration index by 1μ 30 absolute contribution is expressed in the same unit as the c whereas relative contribution was the percentage of the c of each covariate to the total observed incomerelated inequality in mad data quality control the dhs data are comparable across countries the missing values were clearly defined by the dhs guideline if there were missing values and dont know in breastfeeding assumed as not breastfeeding but if there were in specific foods excluded from further analysis 22 the magnitude of mad usage among children in each country was compared with the respective dhs reports c normalized c 1 µ c k ck gc ε µ results socio demographic characteristics of mothers or caregivers a the pooled magnitude of minimum acceptable diet intake among children aged 623 months the overall pooled estimate of the minimum acceptable diet intake among children aged 623 months in subsaharan african countries was 987 with i 2 978 and ranging from 310 in guinea to 2040 in kenya moreover the pooled magnitude of mad intake across country income levels was determined the pooled estimate of mad intake in lowincome countries was 899 lowermiddleincome countries 1175 and 1096 across upper middleincome countries wealth related inequality in minimum acceptable diet usage concentration index and curve the concentration index is used to quantify the degree and show the direction of socioeconomicrelated inequality in a health variable the value of negative sign indicates the more concentration of mad intake among the poor where a positive value indicates concentration among the rich in this study the overall wag staff normalized concentration index analyses of the wealthrelated inequality of mad showed that the prorich distribution of mad intake with c 0191 95 ci 0189 0193 this shows that mad intake among children aged 623 months was disproportionately concentrated on the richer groups the concentration index is twice the area between the concentration curve and the diagonal line then when multiplying the c by 75 1433 which showed that 1433 of the mad intake would need to be redistributed from the richer half to the poorer half of the population to arrive at a distribution with fig 1 the forest plot showed that pooled magnitude of mad intake among 623 children in ssa based on income status an index value of zero the finding from the indices is in agreement with the results of the concentration curves in fig 2 similarly the concentration curve in the following figures showed that the concentration graph of minimum acceptable diet usage was below the line of equality which indicated that the distribution of minimum acceptable diet used children was concentrated in rich households fig 2 the wealthrelated inequality of mad intake was significantly higher among the urban residents than rural and similarly the concentration curve showed that the concentration graph of mad intake among children aged 623 months who were live in urban residence was below the graph of rural residence the wag staff decomposition analysis after the concentration index and curve were assessed and showed incomerelated inequality to the mad intake wag stafftype decomposition analysis have been fitted for those variables that were statistically significant during multilevel analysis and clinical important variables for wealthrelated changes the wag stafftype decomposition analysis is used to decompose the overall incomerelated inequalities of the mad intake by variables and explains the contribution of each factor to the observed inequality table 3 reveals the wag staff decomposition analysis for the contribution of the various explanatory variable for wealth inequalities of mad intake among children aged 623 months in subsaharan african countries the table contains information about coefficient elasticity concentration absolute contribution and percent contribution elasticity is the sensitivity of mad intake for each factor the concentration index in each variable is the degree and direction of socioeconomicrelated inequality in mad intake corresponding to specific explanatory variables the value of negative sign in c indicates the more concentration of mad intake among the poor where a positive value indicates concentration among the rich absolute contribution is calculated by multiplying elasticity with the concentration index of each factor and indicates the extent of inequality contributed by the explanatory variables whereas percent contribution means the contribution of each variable to the overall concentration index in this study more than half of the wealthrelated inequalities of mad intake in children were explained by the combination of variables fitted in the model geographicalrelated factors contribute most of the prorich wealthrelated inequality on the usage of mad among children more than onethird of the prorich inequalities in mad taking among children is explained by the residents having media exposure also explained nearly onefourth of the prorich wealthrelated inequality for children who had taken mad the other 1163 of the estimated prorich inequalities in mad usage are explained by maternal secondary educational status table 3 discussions inadequate infant and young child feeding practices are the major determinants of undernutrition optimal growth and development especially in the first 2 years of life is a major problem both globally and in developing countries 33 identifying and reducing avoidable socioeconomic inequalities and other determinants of malnutrition is a critical step toward improving childrens overall health and wellbeing 14 this study aimed to determine the pooled estimate socioeconomic inequalities of minimum acceptable diet intake and contributor factors among children less than the lowest magnitude of mad intake in our study is in line with research conducted in india which was 9 34 but lower than a multisite study conducted in america asia and africa 21 35 south asia countries 36 bangladesh 20 37 and indonesia 40 38 of children aged 623 can access a minimum acceptable diet the discrepancy might be due to geographical variation population growth and socioeconomic status of the countries 35 cultural beliefs and knowledge paradigms about mad are also known to influence feeding practices 434 studies showed that growth faltering among subsaharan african children becomes evident from early infancy and is sustained through the second year of life which is the period with the highest reported prevalence of overall malnutrition 39 but our finding is higher than a study conducted and in the philippines 67 40 of children aged 623 can access a minimum acceptable diet this is due to the that the current study included a large population from different geographic subsaharan african regions with various cultures beliefs and traditions which make it a real estimation of the magnitude in ssa in this study a significant variation of mad usage of children among ssa countries was observed in which kenya had a significantly higher whereas guinea had a statistically significant lowest magnitude of mad usage am children this is in line with a study in india 34 indonesia 3 south asia 36 and west african countries 41 which reported regional variation in mad usage this might relate to the difference in governmental actions toward the application of national nutritional programs and addressing cultural beliefs around complementary feeding 42 for instance the better magnitude of mad intake in kenya was achieved by implementing a health platform which is called the babyfriendly community initiative platform and by integrating wash into complementary feeding sessions 42 the availability and accessibility of foods in the region may have also a contribution children in agrarian dominant and city dwellers were more likely to have mad 34344 for instance guinea is among the poorest countries in the world which ranks 179 of 187 countries with 10 population were food insecure 45 therfore this low magnitude mad intake might be associated with it evidence also showed that there is an ecological association between dietary diversity and child nutrition in ssa due to ecologyspecific crops production and livestock farming 39 in this study we found that the concentration index and curve result showed that the mad intake was disproportionately concentrated on the rich households c 0191 95 ci 0189 0193 this is in line with a study conducted in india 4647 south asia 36 tanzania 48 it is known that children from a family of higherincome can feed diversified foods and frequently as their families could be more likely to afford to have diversified foods as compared to children from a low household income 49 in this study the prorich inequalities in mad intake were explained by maternal educational status having media exposure of household and living in a rural residence the contribution of secondary and above maternal education towards explaining wealthrelated inequality of mad intake in this study was positive the result was consistent with studies in india 464750 the study in new york also showed that the association of maternal education and child nutrition was positive in intermediate and high socioeconomic conditions 51 the global nutrition report 2020 also pointed out that the education gap contributes 77 of child nutrition inequalities 16 this is might be due to those children of educated mothers having health advantages due to their higher socioeconomic status 47 maternal schooling can help to foster the positive association between household wealth and child linear growth 52 media usage of the household also has a large contribution to explaining prorich wealthrelated inequality of mad intake among children aged 623 mo in ssa this might be due to that those media user households have more likely to be the richest and eventually to feed mad for their kids in this study the concertation of the rural residence was negative for prorich wealthrelated inequalities of mad intake this is in line with studies conducted in india 4753 according to the global nutrition report 2020 the location gap contributes 49 of child nutrition inequalities 16 this is due to that factors that determine nutritional status differ between urban and rural areas nutrition in urban children is characterized by life events of their residence which have a greater dependence on cash income but lower reliance on agriculture and natural resources 54 it is also supported by the multilevel result of this study which showed rural areas had a lower likelihood for mad intake and only 415 of children from rural areas belonged to the richest household wealth status whereas was twofifths of the urban which resulted in a negative contribution the main strength of this study was the use of the weighted nationally representative data of each subsaharan african country with a large sample which makes it representative at subsaharan and regional levels therefore it has appropriate statistical power that can be generalized of the estimates in minimum acceptable diet intake in the study setting to all children 623 during the study period furthermore the concentration index and curve and wag staff decomposition analysis are appropriate statistical models to shows the direction and degree of socioeconomic inequality of mad between the poorest to the richest household since the data were collected crosssectional at a different point in time by selfreported interview would be prone to recall and social desirability bias the drawback of the secondary nature of data was inevitable the heterogeneity of the pooled estimate of mad intake was not managed by further analysis conclusion and recommendations the proportion of minimum acceptable diet usage among children aged between 6 and 23 months in subsaharan africa was relatively low minimum acceptable diet intake was disproportionately concentrated on the rich households secondary and above maternal education having media exposure of household and rural residence were positively contributor whereas breastfeeding was a negative contributor for prorich socioeconomic inequalities in mad intake to increase minimum acceptable diet intake among children age 623 months in subsaharan africa policymakers in nutritional projects and other stakeholders should work as an integrated approach with other sectors and give prior attention to modifiable socioeconomic factors such as promoting womens education and employment increase wealth status and media exposure of the household and promoting breastfeeding behavior the government of subsaharan african countries should plan and work in short terms through the program that endorses women empowerment such as income generation cash assistance for mothers who have under 2 years of children and women employment using affirmative actions and nutrition education such as media campaign and promoting breastfeedings longterm plans are also needed for those ssa countries with lower income status through programs to enhance their countrys economy to the middle and higher economic level and to improve the wealth index of individual households interventions to improve mad practice should not only be implemented factors at the individual level but also be tailored to the community context ssa especially in east africa regions needs equityfocused interventions to curb the inequalities and low magnitude of mad intake not only by taking measures for economic equity but also need the balance by supporting the marginalized group such as uneducated women households with no media usage and rural residence 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 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background child undernutrition is a major public health problem in many resourcepoor communities in the world more than twothirds of malnutritionrelated child deaths are associated with inappropriate feeding practices during the first 2 years of life socioeconomic inequalities are one of the most immediate determinants though subsaharan africa ssa shares the huge burden of children undernutrition as to our search of literature there is limited evidence on the pooled magnitude socioeconomic inequalities of minimum acceptable diet intake and its contributing factors among children aged 6 to 23 months in the region this study aimed to assess the level of socioeconomic inequalities of minimum acceptable diet intake and its contributor factors among children aged 623 months in ssa using recent 20102020 dhs data methods a total of 78542 weighted samples from demographic and health survey datasets of ssa countries were used for this study the data were cleaned using ms excel and extracted and analyzed using stata v16 software the concentration index and curve and wag staff type decomposition analysis were applied to examine wealthrelated inequalities in the outcomes pvalue 005 was taken to declare statistical significancethe pooled magnitude of mad intake among children age 623 months in ssa was 989 95 ci 857 1121 ranging from 310 in guinea to 2040 in kenya mad intake in ssa was disproportionately concentrated on the rich households prorich c 0191 95 ci 0189 0193 residence 3617 media exposure 2393 and womens education 1163 explained the prorich inequalities in mad intake the model explained 5555 of the estimated socioeconomic inequality in mad intake in ssaminimum acceptable diet intake in ssa is relatively low there are moderate socioeconomic inequalities in mad intake in ssa mainly explained by residence media exposure and womens education the government of subsaharan african countries should plan and work in short terms through the

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introduction illicit drug use is a foremost global public health issue facing individuals families and society contributing to significant morbidity among youth and adults 1 in 2014 over a quarter of a billion adults worldwide used drugs and of these individuals 29 million are estimated to suffer from a drug use disorder and 12 million inject drugs it is estimated that 14 of drug users are living with human immunodeficiency virus in 2014 there were 207 000 drugrelated deaths worldwide global regional differences exist in consumption patterns of illicit drug use for example recent trends indicate cocaine use is greater in western and southern european countries whereas amphetamine use is higher in northern and eastern europe 123 the prevalence of illicit drug use among us young adults was 215 and 22 among those transitioning into young adulthood 4 in the usa the most commonly used drugs are tobacco alcohol cannabinoids opioids stimulants club drugs dissociative drugs hallucinogens inhalants and prescription medications 5 cannabis is rated as the most preferred used drug globally with overall use not falling and increasing in some populations 1 adderall is also widely used by young adults 6 among firsttime illicit drug users 25 use nonmedical prescription drugs 63 use inhalants and 2 hallucinogens 5 among young adults there is also a high prevalence of polydrug use ie a combination of prescription drugs and illicit drugs 7 the most commonly used substance is alcohol 42 of young adults have indulged within the past 30 days 4 prescription drugs are readily available in doctors offices and home medicine cabinets and can be bought anonymously without a prescription from drug dealers and through the internet emerging new recreational drugs among young adults include synthetic cathinones bath salts synthetic cannabinoids and salvia divinorum 689 globally illicit drug use is highest among 1825 year olds 1 an age range shared by most active users of internet social media 910 social networking sites are websites where users can share usercreated content in an online community 11 users exchange ideas personal news and photographs while also communicating with friends family strangers and with others who have similar interests 1213 twitter and facebook are the most popular snss with over 12 billion monthly worldwide visitors 141516 young adults most often use sns for communicating entertainment event planning and to send and receive messages meet people and obtain information 151617 sns provide a venue for both synchronous and asynchronous communications that are low cost private and hidden which can make them difficult to monitor 18 19 20 young people often discuss substance use on informal networks therefore sns could be a useful tool to monitor illicit drug use 14 today sns provide access to data enabling epidemiologists to detect credible public health threats such as geographic trends in disease outbreaks 2122 syndromic surveillance collects and evaluates health data and clinical conditions that impact the publics health syndromic surveillance of social network sites is now used for tracking diseases such as the flu and drug safety monitoring common today is the use of sns for tracking internet pharmacy pricing and illicit drug sales 23 24 25 26 27 worldwide the demographics of those who use illicit drugs can fluctuate dynamically over time 1428 every year new types of drugs and drug combinations entice millions of young people to use drugs 78 increasingly epidemiological surveillance of websites such as blogs or twitter messages are used as sources to collect global health data 2930 us government surveillance systems have evolved to monitor illicit drug use the purpose of existing government surveillance systems is to examine population trends in use regarding types of illicit drugs overdose deaths and to identify healthrisk behaviors and gaps in prevention health practices 462328 31 32 33 34 35 traditional surveillance methods in the usa have relied on mandatory and voluntary reporting by physicians the national poisoning data system and laboratories of governmental agencies 233132 healthcare providers and diagnostic laboratories report the data either by legal mandate or voluntary agreement 31 other indirect methods of surveillance include vital statistic reports from hospital emergency departments substance abuse treatment centers poison centers medical examiners and police departments 3336 current surveillance methods for illicit drug use also include national surveys such as the national survey on drug use and health and the behavioral risk factor surveillance system 434 nsduh provides both national and state data on the use of tobacco alcohol and illicit drugs brfss collects data on illicit drug use healthrisk behaviors and preventive health practices the surveys are delivered to adults through random digit dialing and administered through state health departments in collaboration with the centers for disease control and prevention 437 the monitoring the future study and the youth risk behavior survey survey high school students using the us mail system and provided data on the availability of illicit drugs to youths the mtf study found that 90 of study participants indicated that it was fairly easy or very easy to obtain illegal substances 35 these large populationbased surveys eg mtf nsduh are conducted annually with results reported 12 years after collecting the data furthermore these crosssectional surveys rely on participant selfreport as a result they lack the ability to track immediate and emerging drug trends these may include different routes of administration new substances or unique drug combinations intended to entice more users 38 established in 1972 in the usa drug abuse warning network was operated by the substance abuse and mental health services administration and the department of health and human services dawn collected data on substance use and abuse from nonfederal hospital eds from 37 metropolitan states 39 dawn was discontinued in 2011 in the last year dawn estimated that 25 million illicit drug ed visits occurred 39 the research abuse diversion and addictionrelated surveillance is a monitoring system operated by the center for applied research on substance use and health disparities and the national drug control strategy radars collects quarterly and annual data from multiple police agencies poison centers pharmaceutical boards and health departments in 49 us states data collection includes field surveys personal interviews telephone and mail surveys computerassisted interviews and focus groups as well as operations that involve tracing hardtofind interviewees 40 the internet makes the sale of illegal drugs very easy and provides anonymity for both dealers and users 41 in 2014 radars started a web monitoring program that conducts surveillance via the web monitoring program 40 the web monitoring system tracks posts on the internet which are then organized by trained team coders to review and code the data on illicit drug use 42 such data may also be useful as early warnings of specific illicit drug outbreaks despite recent efforts toward more sophisticated webbased monitoring many of the current surveillance methods have limitations including difficulties linking data reliance on retrospective crosssectional surveys delayed reporting inadequate notification system and an inefficient detection of new or emerging illicit drug use 21313643 as a result regional illicit drug use may remain unknown to healthcare professionals until overdoses or deaths are encountered in the emergency room table 1 provides a summary of the us national surveillance systems objective current knowledge of the use of sm as a surveillance tool for illicit drug use remains very limited to address this limitation we examined studies that focused on how social media has been used to identify illicit drug use we conducted a review of the sns literature using preferred reporting items for systematic reviews and metaanalyses guidelines 44 specifically we examined studies that collected illicit drug data from internet web forums 45 46 47 48 49 50 51 and evaluated each study design methods used results limitations and implications for an illicit drug surveillance system also we provide recommendations for promising strategies for collecting analyzing and interpreting sns data to monitor illicit drug use our effort to systematically review studies examining communications about illicit drug use that occur in public dialogs on sns may potentially uncover trends and patterns in illicit drug use that can inform the development of intervention and prevention programs designed to reduce illicit drug use among youth and adults systematic review used were variations of sm surveillance and substance abuse 52 manual searches of letters to the editor and technical reports were also performed we also conducted ancestry and descendancy approaches in the studies obtained method inclusion and exclusion criteria to be included in the review studies had to meet the following criteria original research published in peerreviewed journals primary focus on collecting data on young illicit drug users from sm platforms to analyze or track trends in illicit drug use and publication between january 2005 and june 2015 we began our search in january 2005 because the use of sm has dramatically increased since that time 53 excluded were studies with a primary focus on purchasing prescription drugs from illicit online pharmacies gray literature such as dissertations and theses review papers reports newspaper articles abstracts letters to the editor and commentaries were excluded 54 data extraction and data synthesis the initial search yielded 159 704 citations after applying filters and removing duplicates the articles were reduced to 27 869 next three members of the research team reviewed the papers titles and abstracts for relevance duplication and the selection criteria a total of 295 citations were considered relevant but 276 did not meet the inclusion criteria 19 articles were identified for full review each article was then independently reviewed and five studies were removed from the pool because they did not meet the inclusion criteria the final 14 articles were subjected to full content analysis the final articles were independently reviewed by three researchers the researchers evaluated the studies and reached consensus on inclusion for the analysis interrater reliability between them for yesno inclusion decision was 090 indicating strong agreement 55 discrepancies in the selection of articles for review were discussed until consensus was reached results overview of major findings the heterogeneity among the 14 studies examined precluded a metaanalytic integration instead we provide a comprehensive summary of the 14 studies design methodology major findings and limitations study design the majority of studies were exploratory providing descriptive analyses of sm content 56 57 58 59 60 61 62 63 64 65 66 67 68 only one study used a qualitative study design 69 the others used content analysis of data from sm social media platforms two studies analyzed web forums or message boards 6162 two analyzed data from youtube 6068 morgan et al 60 analyzed more than one sns reviewing data from myspace youtube and facebook 60 five studies analyzed data from twitter 57 63 64 65 66 other snss that were analyzed included facebook and livejournal 5867 participants the studies participants were from the general public college students young adults adolescents and myspace and twitter users sm users ranged from schoolaged children to young adults with the majority reported between ages 17 and 24 years 56 57 58 59 60 one study reported the youngest participant was 11 years of age 69 many participants were college students between 17 and 19 years old who followed musicians with 43 african american 56 illicit drugs used a range of illicit drugs were discussed but the most frequently reported were alcohol marijuana tobacco and prescription drugs two studies analyzed the illicit use of any prescription drug and others focused on particular prescription drugs like opioids or adderall 6166 methodology the selected studies used a broad range of sm toolsapplications including message boards web forums twitter facebook myspace and blogforumsplatform discussions a detailed description of each study reviewed is provided in table 1 most of the reviewed studies followed a twostep process to track illicit drug trends 56 57 58 59 60 61 63 65 66 67 69 in the first step data were collected from the sm chosen for study and prepared for analyses in the second step researchers used the data to analyze trends with the help of software or techniques like spss 61 and stata 58 machine learning algorithms 6364 or hadoop framework 67 in one study cameron et al 62 developed a software application called predose which is a publicly available web forum to collect data and identify emerging trends in drug abuse the software also helped mechanize the mining of semantic data from web forum content to enable illicit drug abuse research using sm 62 major findings all studies reported illicit drug surveillance from sms sites was a positive pursuit however 57 of the studies lacked demographic filters and indicators due to privacy restrictions presenting issues of sampling bias and limiting generalizability 5657 61 62 63 64 6768 convenient small samples also limited generalizability 606869 hanson et al 65 noted their inability to observe actual behavior made it impossible to determine which public tweets corresponded with actual illicit drug use 65 two studies did observe behavior by analyzing storytelling videos on youtube 6068 however moreno et al 59 questioned the validity of information on myspace since the studies were examining alcohol reference which may have been exaggerated 59 in the last decade sm has been used to assess the motivations behind the posting of images and videos of substance use 606768 five of the 14 studies reviewed here used twitter to track trends in substance use 57 63 64 65 66 cavazosrehg et al 56 found that african americans and hispanics disproportionately follow stillblazingtho 56 cavazosrehg et al 57 investigated twitter sources and found that offline and online social networks influenced health behaviors 57 another sns facebook was found to have a potential impact on perceptions of peer alcohol use 58 a qualitative study of focus groups showed similar results ie snss may influence adolescents positive attitude toward alcohol consumption 69 one of the studies suggested that the information in sm can be used by teachers and parents to track how youths interact relative to alcohol use 59 limitations our review revealed several overarching limitations of illicit drug surveillance today information extracted is not always examined for relevance related to illicit drug use and is not always disseminated in the most efficient way there is a lack of standardized system or updates and algorithms to discussion main finding of this study in spite of the limitations noted the current review elicits data that supports the salient role of sns in providing health professionals the public voice and influences that need to be addressed in programs to combat illicit drug use the 14 studies selected investigated how sms and in particular sns have been used to identify illicit drug data acquisition the research indicates clear implications for sm potential as a useful tool for tracking illicit drug use if properly analyzed these publicly available dialogs provide a unique and powerful way to understand substance use among young adults who make up the largest group of users on sns for example twitter tweets extracted by hanson et al 65 include contemporary keywords which identify riskabusive behaviors eg pop crush steal inhale and mimosa among others other publicly available tweets provide insight into substance use patterns and the influence of sm for example this tweet provides insight into marijuana use those who dont understand the beauty of weed purchasing weed rolling and sharing of weed are outsiders and have no business in our world similarly this tweet elucidates prescription drug use effect adderall benadryl has put me in a weird awaketired haze relatively certain that im saying things i wont sic remember in the morning 5665 more timely and adequate findings on illicit drug use from sm could help health professionals design early and effective programs to address substance useabuse according to butler et al 61 examining chatter on message boards could lead to a new surveillance model 61 also cavazosrehg et al 57 concluded that twitter has useful information that needs to be explored 57 every day new sms surveillance approaches are being developed using different resources for example chary et al 23 have proposed techniques to leverage sm to identify patterns of drug usage natural language processing can be used to discover statistical structures in the data further chary et al 23 suggest that machine learning can isolate items from streams of sm and discover the relationships between variables that change over time 23 what is already known on this topic the research on sm surveillance suggests many promising directions for future investigations in all of this research it is vital to educate sm users about privacy policies and the potential negative consequences of posting illicit drug use behaviors online using publicly available media first sophisticated techniques are being developed in machine learning and cloud computing that allow researchers to track trends in substance use 636467 the naïve bayes algorithm a popular text classification technique is relatively simple and computationally efficient 63 second the influences on illicit drug abuse chatter on the internet remains largely unknown 61 butler et al 61 identified the need for studies on internet chatter to compare the use of pharmaceutical medications with abuse rates of these drugs found by hospital eds and poison control centers this approach would provide valuable information on the association between internet chatter and levels of illicit drug use in the community 61 facebook may be a useful tool to distribute information about alcohol prevention programs counseling services or alcoholfree events to college students 58 further research could examine whether sns can be used to reduce the adverse consequences of alcohol use 58 finally it would also be valuable to determine which sm platforms are used most for discussions of illicit drug use this information could potentially lead to the development of a platform to capture discussions about drugs use asynchronously on multiple sm sites future research could then lead to a webbased sm monitoring system for tracking illegal drug use what this study adds in order to address research limitations this review provided a comprehensive evaluation of a number of current studies focused on smss role in surveillance of illicit drug use the results of the current review indicated that there is a clear need to incorporate data mining methods into comprehensive surveillance systems to enhance communities law enforcements and healthcare agencies responses to drug use and emerging drugs however several methodological concerns are evident in the current literature first sm surveillance for prevention of illicit drug use is in its infancy of scientifictechnological development the current focus is primarily on collecting observational and descriptive data similar to other early efforts in health technical services such as neuroimaging and computed tomography scanners 70 second sm surveillance technology is advancing faster than current knowledge as relates to the relationship of human motivation and sm this is not unexpected in light continued of the lack of training and experience health service professionals have with sm third sm can potentially be a useful tool for tracking data relevant to epidemiological and clinical utility this is a limited view since tracking is just one factor in its role of contributing to health service intervention and prevention in particularly as relates to illicit drug use in addition the internet is an important source of information which can be gathered from many worldwide web forums potential biases exist when relying on a particular social platform selected for surveillance specifically users of the platform may not be representative of the population and questions will always exist regarding the intent identity or accuracy of selfrepresentation of the contributors to internet discussion on sm therefore a need exists to identify which social platforms are used most by the public to share their illicit drug use also the development of a dictionary of common words used by illicit drug users would facilitate the surveillance of internet platforms ethical issues in the surveillance of illicit drug use are a longstanding concern in light of current innovative technological advances as seen on the internet ethical issues about surveillance of illicit drug in sm is a new challenge for all professional health service practices the benefits for health professionals are evident since the data retrieved could serve as public health warning and the need for interventions there are many limitations related to the validity and reliability of information retrieved from surveillance systems for example several questions arise regarding the data extracted who retrieved and interpreted the information eg professional epidemiologist was the information extracted from an official or public unofficial source with the high volume and realtime surveillance the data may be obsolete by the time it reaches the health professionals and extraction methods are not well developed relative current standardized procedures the use of sm for illicit drug surveillance is a new concept although social networks are in public domain there are also ethical issues related to privacy protection when using these sites for public health surveillance privacy laws can prevent free access to illicit drug use data which would prevent formal analysis of data by structured institutions eg government agencies legal additionsrevisions of privacy laws are required to address the ethical dimension of the surveillance method by sm a cooperative effort by professional health services organization governmental agencies such as samhsa and the department of hhs community health agencies concerned citizen groups and ethical legal and technological expertise is required to address these issues limitations of this study findings in the current literature should be considered in the context of some limitations the studies examined here were carried out only with publicly available data which may not include some crucial data like geographical location post comment tweet and other personal information like age sex and race this may limit the accuracy of the results obtained another limitation is that when a keywordbased approach was used to find the data misspelled words were not considered nor were synonyms for the keyword 6061656668 restricting the search to a few drugs without considering the most prevalent drugs is a major drawback 606368 another issue found was that when a selected model is applied to a small data set there is always the risk of the model to over fit for example butler et al 61 failed to address this critical issue and therefore their results may be inconsistent with reality conclusion the rise of the internet and sns has led to the evolution of readily accessible information on a global scale regarding illicit drug use current illicit drug surveillance methods have significant limitations including being slow and costly unable to detect new or emerging illicit drugs trends and often dependent on retrospective data 428343771 the development and worldwide use of sm particularly by young adults suggests that people may prefer informal networks such as sm and message boards for discussing their drug use 14 15 16 17 thus worldwide social network data can identify patterns of emerging drug use and data mining tools can complement current surveillance methods 23 national and international health and government organizations including the world health organization need to focus on the potential impact of sm for prevention and treatment of illicit drug use training of health service providers on the role of sm and its evolving technology should be a primary focus for national and global international organizations a vast trove of information with clear realtime updates and identification of new and emerging drugs seems to be untapped therefore worldwide systematic approaches need to be developed to efficiently extract and analyze content from social networks this important work would best be accomplished by a global multidisciplinary collaboration to include health service providers computer scientists mathematicians internet technical specialists governmentcommunity services and public citizens conflicts of interest dmk declares that she has no conflict of interest bb declares that he has no conflict of interest mjl declares that she has no conflict of interest bd declares that he has no conflict of interest ethical approval this article contains no studies performed by the authors using human participants or animals

background the use of social media sm as a surveillance tool of global illicit drug use is limited to address this limitation a systematic review of literature focused on the ability of sm to better recognize illicit drug use trends was addressed methods a search was conducted in databases pubmed cinahl via ebsco psychinfo via ebsco medline via ebsco eric cochrane library science direct abiinform complete and communication and mass media complete included studies were original research published in peerreviewed journals between january 2005 and june 2015 that primarily focused on collecting data from sm platforms to track trends in illicit drug use excluded were studies focused on purchasing prescription drugs from illicit online pharmacies results selected studies used a range of sm toolsapplications including message boards twitter and blogforumsplatform discussions limitations included relevance a lack of standardized surveillance systems and a lack of efficient algorithms to isolate relevant itemsillicit drug use is a worldwide problem and the rise of global social networking sites has led to the evolution of a readily accessible surveillance tool systematic approaches need to be developed to efficiently extract and analyze illicit drug content from social networks to supplement effective prevention programs

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background globally mental health issues including anxiety depression and bipolar disorder account for about 15 of deaths 1 despite practical steps to combat these prevalent mental health concerns millions worldwide particularly women in lowerand middleincome nations suffer from various mental illnesses 2 in the wake of the covid19 epidemic mental health problems have escalated to an alltime high affecting people of all ages and professions especially in developing nations like bangladesh and these disorders include depression anxiety stress sleep issues and addiction 3 4 5 6 7 8 according to a recent nationwide survey 187 of adults in bangladesh suffer from mental health disorders with depression and anxiety more prevalent among women and the elderly 9 during the covid19 pandemic however the prevalence of depression and anxiety among adults particularly students ranged from around 50 to more than 80 3 6 7 8 although mental health disorders are on the rise in bangladesh they are not perceived as a health concern are not prioritized for healthcare treatments and are frequently disregarded 10 in bangladesh people with mental health issues often delay seeking medical help owing to a lack of awareness and shortage of psychiatrists in general particularly in rural and suburban settings 10 moreover preference for traditional or religious healers further delays actual treatment however the most pressing reason for the delay is social stigma a negative stereotyping and prejudiced beliefs and discriminatory behavior towards individuals living with mental health problems and their families 11 social stigma as the canadian sociologist goffman described is a state that disqualifies individuals from full social acceptance 12 this disqualification also prevents those living with mental health problems from seeking help as they are conflicted about the way people might react to or judge their helpseeking behavior 13 in fact social stigma on the part of relatives the wider community and in some cases medical personnel deters individuals living with mental health problems from seeking treatment or in other cases causes them to stop treatment altogether 14 15 16 a study in indonesia suggested that there are different forms of social stigma including personal public family and employment toward professionals and other individuals living with mental health problems 15 studies suggest that the labeling of nonnormal leaves individuals with a feeling of shame thus they avoid social contact and isolate themselves from the community and to some extent from family members 141517 in addition to this labeling of individuals living with mental health problems their family members are also stigmatized and viewed unfavorably by the community 1417 according to a study conducted in norway caregivers are frequently discriminated against by family or coworkers for helping individuals living with mental health problems which put additional strain on their mental health 18 moreover caregivers experience a strained relationship with their care recipients for example a study on caregivers in australia suggested that they often sustain mental health burdens such as tension and worry and are often mistreated by their friends or relatives leading to poor sleep quality 19 although many studies have been conducted in countries other than bangladesh regarding the intensity and consequences of social stigma against individuals living with mental health problems and their caregivers 111415 17 18 19 to the best of our knowledge there is no empirical study that traces the social stigma of individuals living with mental health problems and their caregivers in bangladesh hence this study was designed to explore the experience of these individuals and caregivers and to suggest strategies for combating the societal labeling of people with mental health issues methodology research design the prime focus of this study was to investigate the social stigma associated with mental health issues on this ground a qualitative approach was used because it would facilitate our understanding of the rational foundations upon which our subjective experiences judgments and opinions might build when explaining human behavior thought and action 20 conclusion and recommendations in bangladesh the majority of individuals living with mental health problems are stigmatized and do not receive emotional support hence we suggest nationwide communitybased awarenessbuilding programs to promote more positive perceptions of the fight against mental health disorders furthermore counseling and awarenessbuilding programs for effective discouragement of nonscientific remedies such as spiritual healing as well as diagnosis and medication at the primary stage of sickness are recommended for early detection and better medical assistance keywords mental health person living with mental health problems student social stigma social perception bangladesh study subject the target group of the research was university students experiencing mental health issues caregivers of individuals afflicted with mental health issues were also recruited in order to attain insight into their loved ones conditions some specific criteria were followed when recruiting the student participants the participant must be a student enrolled in a regular educational program when recruiting caregivers the criteria were they must be close to the individuals living with mental health problems have indepth knowledge and a willingness to take care of the individuals living with mental health problems furthermore we used purposive sampling to select our eight student participants from nonclinical settings as it enabled us to make initial contact with a small network of individuals who were relevant within the field of investigation and accordingly utilize them as a springboard to expand the scope of the research 21 when selecting the caregivers we used convenience sampling because it helped us to gain important insights into any specific investigation issues arising from the minimal number of sample cases 2223 in qualitative research it is possible to make generalizations even from a very small number of sample participants 21 accordingly it is also worth mentioning that due to the sensitive nature of the research and the confidentiality needs of the participants the sample size was very limited in number interview outline we designed a semistructured interview schedule in order to gather firsthand information based on a review of the pertinent literature the interview schedule was broken down into four parts individuals receiving mental health care were initially questioned about their personal and family background and their living arrangements in addition questions about the individuals living with mental health problems and caretakers mental health experiences and social responses were included in sects 3 and4 respectively data collection the study encompassed two stages of data collection in the first stage eight individuals living with mental health problems living in khulna were interviewed over two consecutive months in the second stage five indepth interviews were conducted with the caregivers of the individuals who were living with mental health problems prior to data collection informed consent was sought from the participants for their voluntary involvement all the interviews were conducted in bangla and there were no pauses or interruptions each interview lasted about 4050 min on average with participants informed consent the whole interview was recorded verbatim for later replay interviews were held in the strictest confidence and every participant had the option to withdraw from the study at any time with no questions asked as such we were able to gather data while maintaining a cordial connection with the participants since we were in an objective position to ensure the accuracy of the data and eliminate any prejudice we exercised prudence during the interviews and adhered to the golden rule of unconditional acceptance by attentively listening asking clarifying questions and providing comprehensive responses however it appeared that the research had become saturated after the sixth interview and data collection was halted after the eighth interview in this regard we must clarify that in qualitative research saturation is often claimed to be somewhat justified or explained 21 it is worth mentioning that small sample size particularly in interviewbased qualitative research helps researchers to increase their chances of gaining participants trust and collecting detailed information which was important for this study 21 because individuals living with mental health problems in bangladesh are often stigmatized therefore they do not open to people due to trust issues data analysis following the completion of the interviews the transcribed data were coded and interpreted into themes using the qualitative data analysis software nvivo 12 each author contributed to the summarizing of essential points and the setting of the stage for the themes data were analyzed using thematic analysis because using thematic analysis it is possible to see which themes are most essential to the explanation a phenomenon under study moreover the results of a thematic analysis draw attention to the most prominent clusters of meaning within the data set we established a connection between the studys findings and external circumstances by correlating the themes frequency of occurrence in addition following each interview we deliberated on what to include in our preliminary analysis and reached a consensus meanwhile we carefully examined and evaluated the interview data to resolve any discrepancies and in extreme circumstances rule them out completely results and findings background information of the informants of our 13 indepth interviewees eight informants were firsthand sufferers of mental health issues who were undergoing medication and the remaining five were caregivers of those individuals living with mental health problems according to the background data provided by the informants six of the eight individuals living with mental health problems were unmarried male students and four of these male students had no earnings the other two male students had an income from private tutoring to other students in addition to the six male students there were two married female informants most of the informants with mental health issues were living with their family members such as parents or husbands the background data also showed that all eight individuals living with mental health problems were aged between 21 and 25 years all informants had first reported their mental health problems in the previous ten years three of the five informants who provided care were housewives while the other two were men who were involved in business based on the qualitative data we gathered from the field our results generated four significant themes including some subsets of themes these were 1 mental healthrelated problems and seeking remedies 2 family perception support and response to mental healthrelated problems 3 social stigma and labeling of madness 4 reaction from the community to mental health related problems mental healthrelated issues and seeking remedies the qualitative data shows that six of the informants living with mental health problems had received supportive responses from their families however all but one of these informants claimed that their family members were hesitant to talk about these issues with strangers these families considered mental health problems to be a private family issue moreover they acknowledged the need for confidentiality due to the communitys poor perception of matters relating to mental health additionally the social stigma associated with mental illness which is linked to insanity can cause a family to suffer from ongoing humiliation and misery all of the informants concurred that the communitys unfavorable attitudes and responses would negatively impact individuals living with mental health problems and trying to overcome the situation although the positive response from the family regarding mental health issues was sometimes early and sometimes delayed it always significantly contributed to improving the individuals mental health two themes illustrate families reaction to the informants mental health issues i seeking medical support ii seeking spiritual supportfaith healing seeking medical support at least six of the informants living with mental health problems said that their families had sought the support of a clinician in order to address the health issue informant 1 shared his experience in this regard from the very early stages of my problem i was content with my familys support my family immediately contacted a psychiatrist to seek remedies and motivated me to spend more time with my closest friends they positively believed that spending more time with my peers and family members would aid me in fast overcoming my mental health problems although some informants were hesitant to share their mental health issues with their family members independently the family members observed the anomalies in the individuals behavior and took positive action to seek treatment for instance informant 4 reported i have been suffering from mental health problems for more than a year my medication is ongoing as i still have not recovered properly truly speaking i neither shared nor explained this to my family at the initial stage of my problem however my family members particularly my elder sister observed my behavioral abnormalities and understood that i was going through some mental disturbances they immediately sought guidance from a psychiatrist and consulted for remedies informant 5 reported a slightly different but similar experience to informant 4 the experience of informant 5 demonstrates the importance of family support for an individual living with mental health problems which is continuing with longterm treatment recovery from mental health issues takes time therefore ongoing family support is required as informant 5 said i was out of control at the beginning of my mental health problems i did not understand the process and anomalies i faced then and was annoyed to share this with anyone in particular fortunately my family members could detect my problems immediately and they took me to a psychiatrist my family took me to a different psychiatrist because the first one failed to help me much we found that the second psychiatrist was helpful with the counseling and medication seeking spiritual supportfaith healing outside the medical support system many families still believe that mental health issues are a spiritual problem and seek spiritual or faithbased solutions the qualitative data showed that two of the interviewees had a spiritual definition of their mental health problems and their families had sought faith based healing for the problem these families had also searched for a religious solution to the issue however these two informants lower level of education and their location in isolated rural places may be why they chose not to seek emergency medical assistance in rural areas mental health difficulties are still considered to have a paranormal explanation and many people choose to turn to spiritual therapies the experience of informant 3 demonstrates this upon sharing my family ignored my mental health issue they considered my problem as a paranormal issue and contacted a local kabiraj 1 within months they consulted three more local kabiraj all the kabiraj concluded that my problems are activities of dissatisfied souls therefore they applied their incantation and traditional treatments over me this took months while the situation worsened after months of the kabirajs treatment my family finally shared my issue with one of our relatives my relative instantly suggested contacting a psychiatrist the findings from the aforementioned two themes suggest that the informants families often had mixed perceptions of mental healthrelated problems the interviewees indicated that those who received immediate and proper family support and consultation with a psychiatrist had a quicker recovery than those who were taken to local faith healers informant 2 who was taken to a local kabiraj asserted that my family members contacted many kabiraj and fakir 2 and they told us that it was the influence of an evil spirit and someone might have performed black magic on me however after receiving kabiraji treatment my situation deteriorated until my fam 1 localtraditional healers who largely expand their practices on faith healing they are recognized as quacks in the modern health system 2 spiritual healers hold strong religious beliefs about treating patients ily took me to a medical practitioner my condition did not improve family perception support and response to mental healthrelated problems among our 13 informants five were direct and close caregivers of the individuals who were living with mental health problems all five caregivers admitted that they considered their family members mental health problem a critical issue that needed to be resolved however most of them also reported that they had not anticipated this kind of health crisis in their family in each case the whole family had eventually become concerned after learning about the mental health problems of their loved ones one caregiver explained that when i first heard about my daughters mental healthrelated problem i was puzzled and sad i must confess that the whole family underwent a mental health crisis hearing my daughters case all the caregivers reported that their closest who suffers with mental healthrelated problems had caused the family to undergo much propagation and speculation hampering their personal family and public images and lives as a result the original choice of action was not always in the informants favor a mental health issue for one individual appears to be a robust depression and anxiety producer for the family as a whole sometimes negative speculation worsens the situation for instance caregiver 3 explained their experience of this first all my family members were somewhat speculative about my wifes mental health issues i must admit that it was not a positive reaction and speculation that put the family into a disturbance we wondered if my wife was having an extramarital affair with someone else she also acted like she had a mental health disorder that was not real under this speculation we sent my wife to her parents house a family may delay vital medical support due to negative speculation community beliefs can lead the family to consult a religious healer or adopt spiritual solutions these beliefs are sometimes inherited in this regard caregiver 2 reported that when we realized that my son was suffering from mental health issues we took him to the kabiraj at an early age his grandfather also had this problem and was taken to the local kabiraj and fakir following the experience we gradually contacted many kabiraj and fakir all of them said that an evil spirit had captured my sons soul there was also speculation from the kabiraj that someone may have used black magic on my son we had faith in their stories and continued with their treatments however those families who utilized faith healing or spiritual solutions ended up prolonging the individuals mental health crisis all the informants who had contacted kabiraj and fakir at an early stage for a solution said that they later had to consult specialized medical practitioners in order to ensure a better result for their individuals living with mental health problems social stigma and labelling of madness our early findings demonstrated how family support is essential when dealing with mental healthrelated problems nevertheless both individual living with mental health problems s and families also had concerns regarding the acceptance level from the community therefore in determining whether an individual or family will communicate such issues at a mass level it is crucial to understand how the wider community responds to and accepts mental health difficulties the indepth interviews showed that although four informants did not face any labeling their community support system was lacking although individuals living with mental health problems could have benefitted from community support they admitted to facing hurdles in the shape of friends neighbors and other community members the other four informants who were living with mental health problems said they had faced labeling were stigmatized and felt unwanted by many of their friends and neighbors they found that people used the terminology of madness as equivalent to mental disorder all four of these informants asserted that people of all ages had laughed at them in their presence or absence they also found that some people made up irrelevant rumors or engaged in superficial talk such as stating that the informants madness had resulted from their sins or misdeeds informant 3 reported this type of upsetting experience i was very depressed to see my closest friends reactions besides my mental disturbance their behavior also put me further into depression their disregard toward my illness was intolerable and their rumors about me worsened my condition and left me traumatized for instance many of them suspected me of having an extramarital affair they even considered my symptoms of illness to be unreal and thought that i was acting moreover they labeled me as mad or crazy similarly it was challenging for families to talk about the informants mental health problems in public damaging community acceptance with madness usually risks the respect and dignity of the family thus almost all the caregivers admitted that they did not want to share their family problems with the wider community they argued that harmful comments from relatives and neighbors would stigmatize the family and negatively impact the informants health of this experience caregiver 4 asserted that though we did not allow my daughter to interact with outsiders we failed to stop our neighbors from intimidating her we heard that some of our relatives and neighbors started mocking my daughter in her absence their mockery humiliates our daughter and puts our whole family into embarrassment unfortunately we did not get our communitys support instead they taunted us verbally and mentally the people in the community labeled my daughter as mad and us a mad family caregiver 5 also shared her negative experiences despite his mental health issues i encouraged my son to maintain a good relationship with our relatives and friends however my son was labeled as mentally unbalanced and mad his university friends and cousins started ignoring him the humiliation in the social support system was very stressful for my son although a small number of people acknowledged receiving some support from those close to them this compassion could not displace the idea of madness with regard to issues relating to mental health whether supportive or nonsupportive the community as a whole labeled mental healthrelated issues as madness indicating that the individual living with mental health problems was mentally imbalanced or a lunatic caregiver 2 expressed her opinion on and experience of this most of our relatives and neighbors were supportive regarding my sons mental healthrelated problem the fact that they refused to stop calling my son crazy hurt us the most they sympathized with my son but also taunted him with the lunatic expression for instance some of them said ahhh he was a brilliant student but became mad like his grandfather these expressions in our presence as well as in our absence in public were stressful reaction from the community to mental health related problems individuals living with mental health problems can either benefit or face challenges from their friends neighbors and other community members our indepth interviews showed that half of the individuals living with mental health problems did not experience any labeling as their neighbors and community members supported them in addition the communitys suggestions and mental supports helped the person living with mental health problems an early recovery informant 1 who resided in a student hall stated that i shared my problems with my best friends they were incredibly supportive and helped me to handle my issues they inspired me and said positive words that there are some ups and downs in everyones life and i must have patience conversely the rest of the informants experienced labeling stigmatization by friends and family moreover they asserted rigorously that people from all backgrounds and ages had humiliated them and their families they were labeled as mad and treated as insignificant of this experience informant 3 stated that i was traumatized by the intense mental pressure from our close family members their suspicion of me and my life was disturbing as a result of their doubts and rumors my inlaws started to dislike me and i was shamed in front of my parents none of this helped me to improve my mental condition discussion this qualitative study aimed to investigate the stigmatization experienced by individuals living with mental health problems and their family members the results and findings section presented the perspectives of eight individuals living with mental health problems and five caregivers who were interviewed for this purpose with their experiences related in thematic order the findings revealed how mental healthrelated issues and remedies were handled by individuals living with mental health problems and their families it also showed how family support was provided considering both the community response and perception of mental health issues all informants in this study were between the ages of 21 and 25 with their first experience of mental health difficulties occurring in the previous ten years 24 this is considered the peak time for the onset of mental illness which comprises anxiety and depression 25 in certain instances family members proactively consulted doctors for medical assistance and permitted the informant to spend more time with their peer groups 26 however the individuals living with mental health problems occasionally experienced the reverse instead of sharing mental health issues with doctors some families preferred to keep them confidential they believed that telling others could violate their familys code of honor carr and ashby 27 found that people view the identification of mental healthcentered issues such as anxiety and depression as derogatory and discriminatory furthermore there was a mixed response from family members toward individuals suffering from depression or anxiety skundbergkletthagen wangensteen 18 state that in many cases relatives have feelings of anger and irritation toward the depressed member of their family since the situation is restricting them from leading the peaceful life they want to live for instance ahlström skärsäter 28 have shown that when a family has a mentally troubled child it affects the relationship between the spouses which is sometimes characterized by verbal aggression and accusation caqueourízar and gutiérrezmaldonado 29 further opine that informants family members suffer psychologically and socially due to having a mentally unhealthy person in their household to overcome the problems of depression anxiety and mental healthcentric distress we identified two genera of support namely i medical assistance and ii spiritual assistance seeking medical assistance was very common among the informants the pattern of the helpseeking behavior of depressed individuals and their families was contextspecific it was clear that some participants would have preferred to consult a medical specialist or mbbs doctor but due to financial insolvency and geographical inaccessibility they instead consulted local village doctors and faith healers 30 the literature has also found that seeking spiritual assistance is a prevalent practice ngoma prince 31 report that many individuals living with mental health problems consult traditional healers for spiritual treatment many families of mentally distressed individuals strongly believe that depression and anxiety are not a disease but instead a curse resulting from witchcraft and evil spirits 3233 we also found a prevalence of delayed response in terms of treating depressed individuals with proper medication many of the families strongly believed in the supernatural and magical aspects of causing and curing mental illness 34 in treating depressed individuals these family members preferred to consult traditional healers in developing countries traditional healers are often seen as the primary agents for treating individuals struggling with psychosocial noise 35 in this paper we detected that the culture of preference for traditional healers ie fakir or kabira still persists in bangladesh picco abdin 36 have also mentioned that adopting poorer treatment can be a mitigation tool and that delays in appropriate treatment have negative consequences for individual mental health outcomes when a family member first learns that their relative has a mental health issue their perspective is one of confusion and anxiety they have no idea what to do and what not to do whom should they contact in order to overcome the problem all of these factors affect their own mental health this stressful ambience inside the household also makes the depressed individuals more depressed brelandnoble wong 37 have also detected that individuals struggling with depression are more exposed to family arguments than nondepressed individuals these arguments relapse the somatic symptoms of depressed individuals and push them into the vicious circle of depression 38 in addition sometimes family members become speculative regarding the depressive symptoms of the individual in this study we found that one of the depressed female individuals had inlaws who suspected that she was only faking madness and that she might be having an extramarital affair the findings of selim 30 are consistent with our result she argues that people hardly recognize depression while the participants she surveyed termed it as china rog caused by financial weakness however sanz and garcíavera 39 state that an individual can experience depression despite everything else in their life going well from the indepth interviews our findings show that some informants do not experience the labeling of madness however support from their peer groups and surroundings is inadequate lauber and rössler 34 have found that in asian countries the tendency of communities to stigmatize and discriminate against individuals living with mental health problems is widespread mentally distressed individuals are considered dangerous which yields an inclination to maintain a safe distance from individuals suffering from anxiety and depression therefore the adverse societal reactions of communities towards mentally unwell individuals are pervasive this worsens the person living with mental health problems condition and limits the scope of their social integration 40 it also relapses the selfstigma of the mentally distressed individuals which is assimilated with the social stereotypes and causes loss of selfesteem and deterioration of selfefficacy this ultimately makes the individual and their family members hesitant to socialize moreover many participants reported not knowing that something was wrong sometimes for years one participant did not seek treatment because they didnt know anything was wrong with me a similar situation has been observed among person living with mental health problems suffering from depression in the usa 41 limitations the selection process of the study location and informants does not provide a full representation as the study location only represents a single locality among the whole of bangladesh and the informant groups were a tiny portion of a larger population therefore the findings we have concluded from the data have limitations concerning generalizability to the wider group of individuals living with mental health problems in bangladesh another limitation of this research was that we gathered information directly from the informants living with mental health problems and caregivers who were susceptive of the issues however this rapport building was influential in ensuring a comfort zone between the informants and the interviewers other restrictions we must address include problems with funding a lack of time and communication difficulties for example in investigating the sensitive topic of mental health problems we found it challenging to arrange appointments and schedule interviews with individuals living with mental health problems and their caregivers communication was another problem as most informants were hesitant to provide data on this sensitive topic moreover the data were collected during the covid19 lockdown the related safety precautions interrupted the data collection procedures and communication which posed another challenge for this study we also acknowledge that further data from a wider range of informants who are living with mental health problems around the nation would be necessary in order to declare the findings generally applicable however we believe that apart from these limitations this current study can potentially contribute to mental health literature and could also be significant for comparing or contrasting data in the relevant field conclusion and recommendations the social stigma regarding individuals mental health problems hinders disclosure of the problem especially among the family of individuals living with mental health problems community relatives and peer groups both individuals living with mental health problems and their families frequently attempt to keep such problems hidden from the public and their neighborhoods usually society labels mental health problems as madness and imposes a social stigma which causes nondisclosure of the problem on the part of the informant and their family the communitys perspective on this matter constitutes a restriction on the openness of society which needs to be addressed delicately in bangladesh as in many other underdeveloped nations mentally ill people are not adequately understood by the community due to the lack of social acceptance families frequently struggle with regard to telling the wider community about any mental health concerns that affect their family members in response to mental health problems the individuals living with mental health problems and their family members primarily try to find ways to move away from the illness therefore they seek help from psychiatrists the success of psychiatrists varies sometimes they are effective and sometimes not however a quick response and effort from the mentally unwell person and their family members to improve the mental health condition and regain the mental stability of the individual as well as a diagnosis are essential at the initial fastmoving stage of the mental health problem in this regard the role of family members relatives and peers is essential in most cases a diagnosis and medication at the primary stage of the mental health issue can provide better health outcomes therefore a prompt and visible response to the problem by family members is highly beneficial in combating mental health issues as such awarenessbuilding programs using electronic media such as television radio and social media could be an effective instrument to upgrade the social lens toward handling and accepting individuals living with mental health problems additionally different awareness programs as well as government and nongovernment organizations should promote medication and pragmatic rehabilitation programs for mentally ill people it has been found that when dealing with mental health problems people frequently seek nonscientifically validated spiritual remedies and local faith healers this preference occurs due to belief in superstitions and ignorance which often worsen the individuals condition however counseling and awarenessbuilding programs can effectively prevent use of spiritual or faithbased treatment discussion of mental health problems and the procedure of dealing with individuals living with mental health problems by their families communities peers relatives and societies in the textbook at different stages of education can bring longterm constructive changes in the social settings it was also found that one family members living history of mental illness can cause the mental health problem of other family members especially regarding depression anxiety and stress to worsen families also often feel that society is looking down on them which creates an extra mental burden that may prolong their efforts to find a road to recovery for individuals living with mental health problems consequently positive mental support from society community peers and relatives are highly recommended in order to break social perception bottlenecks and boost the acceptance of individuals living with mental health problems abbreviations competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to 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background worldwide mental health issues constitute a substantial threat to peoples social economic and mental wellbeing and contribute significantly to many fatalities each year in bangladesh people with mental health issues typically delay contacting health professionals because they prefer traditional or religious healers moreover the situation is exacerbated by a lack of awareness social stigma and negative perception of sufferers of mental health issues on the part of families and the community therefore this paper investigates the social perception and stigmatization of individuals living with mental health problems and their caregivers in khulna bangladesh methods data were collected from university students with concurring mental health issues as well as their closest caregivers who had indepth knowledge of the problem and a willingness to take care of the individuals with mental health issues following the criteria for data collection eight individuals living with mental health problems and five caregivers were purposively selected for this research a semistructured indepth interview guide was used for the confidential data collection process which took place in november and december 2021 and each interview lasted 4050 min on averagethis study used thematic analysis to present the results the findings showed that individuals afflicted with mental health problems sought both medical and spiritual support to recover those with mental health issues who received positive family support recovered relatively faster than those who did not however negative social perception and stigmatization were the key impediments for individuals suffering from mental health problems and their families as they found it difficult to discuss their issues with relatives and communities when attempting to access support or seek remedies moreover the commonality of social stigmas such as labeling mental health problems as equal to madness hindered disclosure to family members peers and the community

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romantic and sexual relationships which begin at a relatively young age are associated with an increased risk of maladaptive outcomes and an adverse influence on relationship skills and sexual functioning in later life in the uk teenage women are at highest risk of acquiring bacterial sexually transmitted infections that can cause pelvic inflammatory disease ectopic pregnancy and infertility and there is evidence that the trend is worsening about 20 live births per 1000 in the uk are to teenage mothers and the prevalence of sexual debut before the age of 16 has increased compared to a decade ago with more than one in four young adults reporting sexual activity before their 16 th birthday in a large international survey the mean age of sexual debut in the uk is reported as 14 years for both boys and girls study chapter 3 young peoples health and healthrelated behaviour but data from a sexual health care service centre in wales reported that the median age of sexual debut was 12 years for boys and 13 years for girls in the five percent of cases in this welsh cohort where there was a record of possible coercion all clients reported that intercourse was consensual existing research on adolescent sexual behavior has shown that there is a predictable sequence of behaviors which occurs as adolescents become involved both romantically and sexually romantic and sexual behaviors progress from hugging and holding hands to kissing and touching breasts genitals over and then under clothes and on towards increasingly intimate behaviors like being undressed together and ultimately coital activities such as oral sex and sexual intercourse in general boys show an earlier and more accelerated development towards sexual involvement than girls much of the work examining the development of romantic and sexual relationships in adolescence has been retrospective or undertaken in clinical populations where the prevalence of risky behaviours might be overestimated children who have been sexually abused are reported to display more sexual behavior than those not exposed to abuse and in high income countries including the uk 510 of girls and 15 of boys are exposed to penetrative sexual abuse during childhood thus there is a need for prospective data from representative cohorts regarding the development of romantic and sexual relationships from onset so that ageappropriate effective sex education sexual health promotion and interventions can be developed the aim of the current study is to provide a prospective description of the development of normative romantic and sexual behavior in early adolescence in a uk cohort as we are unaware of any other studies which have undertaken this work data about romantic and sexual behaviors with another young person and the context surrounding these intimate episodes were collected at two consecutive time points from a large populationbased british cohort of adolescents aged 1113 years we expected that the prevalence of romantic and sexual behaviors in general would increase over time but that at each individual time point the proportion of the cohort engaging in these behaviors would decrease as the behaviors themselves became more intimate methods participants the avon longitudinal study of parents and children enrolled 14541 pregnant women between april 1991 and december 1992 mothers consented to join the study at recruitment and were free to withdraw at any time due to attrition which is a common feature in longitudinal studies the cohort size has reduced over when compared to 1991 national census data the alspac sample at recruitment was similar to the uk population as a whole having only a slightly higher proportion of married or cohabiting mothers who owned their home and a car there were also a slightly smaller proportion of mothers from ethnic minorities further information about the cohort can be found at the study was approved by the alspac law and ethics committee and the local research ethics committees data collection we used a computer assisted selfinterview at each time point children aged 11 12 years were asked about precoital romantic behaviors and those aged 12 13 years old were also asked about more intimate behaviors including sexual intercourse we stipulated that we were only interested in behaviors which had occurred during the previous year and which had taken place with young members of the opposite sex who were not related to the participant him herself the casi was adapted from the adolescent sexual activity index a hierarchy of ten romantic and sexual activities we added questions about reciprocal behaviours and about the context of romantic and sexual encounters including enjoyment or regret and contraceptive use to obtain information about readiness for sexual activity we did not ask about sexually abusive experiences or masturbation study parents gave consent for their children to take part and study children assented to complete the casi in the interview each item was presented sequentially there were several points at which the interview could end depending upon the participants responses the interview ended if the response to both items about kissing and cuddling was no or if the response to item 6 have you lain down together was no if the study child answered no to both items 7 and 8 the interview ended from this point on the interview would only continue if the study child reported that they had been involved in an activity as soon as the response was no the interview ended because of the gender differences in involvement in romantic and sexual behaviors analysis of the data for the presence of the event and also the extent to which it was enjoyed or regretted was carried out separately for boys and girls in the data analysis we calculated the percentage of boys and girls who had taken part in each activity and then for those with experience of the behaviors we calculated the proportion that reported enjoyment of the activity and the proportion that regretted their involvement as we were interested only in whether or not the event had occurred whether it was enjoyed or regretted and whether or not a condom was available at that time we dichotomized these variables and used chisquare tests to examine gender differences for each outcome results at 1112 years 6856 children of the 7218 who attended the clinic provided data about romantic behaviors at 1213 years 68017011 provided data mean ages at interview were 118 years and 129 years overall 245 of 11 year olds had held hands with someone and 162 had kissed another person one year later 409 had held hands with someone 326 had kissed another person and 342 had cuddled with someone more intimate behaviors which were asked only at the second clinic were reported much less frequently for girls and boys combined 118 of 12 year olds had lain down together with someone of the opposite sex and 49 reported petting or coital behavior including activities from have you been touched under your clothes to have you had sexual intercourse in both age groups girls were less likely than boys to report involvement in all activities details of the proportions of girls and boys involved in each activity are shown in table 2 fewer than 1 of girls and just 1 of boys reported coital behaviors at 12 years of age most study participants said they enjoyed their romantic and sexual experiences although girls reported less enjoyment than boys girls were more likely to report regret the largest gender differences were for behaviors where children had been touched rather than having touched someone elses private parts 653 of girls compared to 847 of boys who had done this reported that it was enjoyable but 289 of girls compared to 144 of boys reported that they regretted it for sexual intercourse almost all girls and all boys reported having enjoyed it about 40 of adolescents who had experienced intimate petting behavior did not have a condom with them at the time of those who had sexual intercourse all girls and 781 of boys reported that they had used a condom discussion in this uk cohort around one third of young adolescents have taken part in romantic behaviors beyond holding hands but far fewer study participants have engaged in more intimate behaviors boys are more likely to engage in romantic and sexual behaviors than girls and they seem to be more active in the initiation of such behaviors girls generally report less enjoyment and more regret amongst 12 13 year olds only 06 of the cohort have had sexual intercourse but more girls than boys reported using a condom data from the hsbc survey reports that in 20012 around 70 of 15 year olds in the uk used a condom the last time they had intercourse which is more consistent with our results for boys than for girls we are unable to explain this discrepancy in our data it may be that younger girls who are facing their sexual debut are more conscientious about condom use to begin with at least but that such conscientiousness lapses as they become increasingly aware of girls who get away with unprotected sex alternatively fear of pregnancy may mean that young girls are more aware of the social desirability of condom use and report their use even if this is inaccurate study chapter 3 young peoples health and healthrelated behaviour in support of data from other studies which suggests that sexual debut occurs at around 12 to 14 years study chapter 3 young peoples health and healthrelated behaviour it would seem that we have managed to capture data from the cohort as they were approaching the threshold for sexual debut girls were less likely to report intimate behaviors despite on average being at a more advanced stage of puberty than boys of the same age these results are consistent with previous research examining the progression of romantic and sexual behavior in adolescents a larger proportion of girls were also passive recipients rather than active initiators of many of these romantic behaviours and girls were less likely to enjoy and more likely to regret activities than boys the level of regret reported here is consistent with that reported in previous research we have shown that data about precoital and sexual romantic behaviors can be collected prospectively from early adolescence onwards and that the computerassisted interview was well accepted there are several strengths to this study first the alspac cohort provides a unique opportunity for the prospective investigation of the development of adolescent romantic and sexual behaviour in a large populationbased as opposed to clinical sample the very low prevalence of sexual intercourse in 1213 year olds suggests that the casi was administered around the time of transition from noncoital to coital behavior the reporting of the more intimate and coital behaviors in our study is likely to be more accurate than those in which the timing of onset of sexual behavior is examined retrospectively on the other hand romantic behaviors that occurred earlier in childhood might be subject to recall bias second the size of the cohort means that the estimated prevalence of romantic behaviors has been described with high precision finally the alspac dataset contains many childand familybased variables collected at least annually since the birth of the child consequently future research will be able to examine pathways to the early onset of sexual activity predictors of passive versus active involvement and also resilience as well as both risk and protective factors for adaptive as opposed to adverse psychological and biological outcomes a limitation of our findings is that we were required by the ethics committees to use a strictly hierarchical sequence of intimate behaviors which forced us to stop the interview as soon as a child responded that they had not been involved in a specific behavior this might have resulted in an underestimation of the frequency of intimate behaviors but we believe that any bias is likely to be small because previous research has reported strong evidence of sequential increases in intimate behaviors findings from this study support previous research in the united kingdom by showing that some adolescents become sexually active at a very early age in conjunction with the risks associated with early sexual debut this means that comprehensive sex education is essential if the health of young people is to be maintained although the united kingdom national curriculum advises that relationship skills be taught in schools from ages 5 7 onwards this guidance is nonstatutory and sexual behaviors are not mentioned in sex education materials until age 11 14 years in order to be effective the promotion of sexual health to adolescents must be based on accurate data about the onset of development of romantic and sexual behavior sex education programs should take into account young peoples enjoyment in early romantic involvement but also the fact that some teenagers might not be emotionally prepared and regret it promoting confident communication about sexual feelings could help adolescents delay sexual involvement until ready and help prevent unplanned pregnancies and sexually transmitted infections our results suggest that sex education programs should discuss romantic and sexual behaviors before 11 years after each question we asked how much did you enjoy…… additional contextual questions from question 7 onwards we asked how much did you regret… after each question notes these are novel items added by the authors for the purposes of this study a not asked in this study b did you have a condom with you asked after each question c did you use a condom asked after this question mean age of 11 year olds 118 years and 12 year olds 129 years b items scored as 1 not at all 2 a bit 3 quite a lot and 4 very much note enjoyment those recording 3 or 4 were categorized as having enjoyed the activity regret those recording 1 were categorized as having no regret c for the final item this item was rephrased as did you use a condom

adverse outcomes of teenage sexual activity are common in the united kingdom we used a computerassisted interview to ask young adolescents aged 1112 years n 6856 and 12 13 years n 6801 who were part of the avon longitudinal study of parents and children about romantic and intimate behaviors 24 of 1112 year olds and 41 of 1213 year olds reported holding hands and 17 and 32 respectively reported having been kissed on the mouth a minority of 1213 year olds reported sexual behavior including intercourse the majority of participants who reported intimate sexual behavior did not regret it boys reported all activities more than girls and were less likely to express regret our findings suggest that the timing and content of sex education should take into account the frequency with which young people are experimenting with sexual behaviors

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i introduction cooperation evolution emerges in diversities of social networks by way of individuals interactions and influence propagations the spreading dynamical processes of cooperation on complex social systems have been received more attention because of the multiplex nature of social networks and social interactions which reflex the intimacy differences of the social relationships in reality 1 in recent years some researchers have investigated the mechanism and process of information diffusion 2 5 innovation adoption 6 and strategy behavior 7 8 the two basic diffusion models are generally used to analyze the diffusion dynamics in complex networks the independent cascade model 9 11 and the linear threshold model 12 13 many potential factors that may affect these spreading processes on complex networks have also been explored including individuals attributes the associate editor coordinating the review of this manuscript and approving it for publication was hocine cherifi tie degrees distributions and different topological structures of network 14 17 etc it is an important step that identifying the most influential spreaders in social networks towards optimizing available use of resources and ensuring the more efficient information diffusion and cooperation evolution 18 20 it is also found that the most influential spreaders are those located within the core of network which could be identified by the kshell decomposition analysis 21 23 moreover the impact of the rational decision of individuals on outcome of the cooperation evolution also was investigated including the trust level of individuals and influence force of communities and memory ability of individuals 24 26 etc nowadays scholars have gradually directed their interest from the monoplex networks to multiplex networks 11 27 28 and simultaneously considered the timevarying and multilayer character in diffusion processes 2 29 30 specially social systems are also viewed as the interdependent complex social networks consisting of many subnetworks where subnetworks may have different types of structures interlayer links and intralayer links account for different kinds of social relations and social interactions 31 33 as a natural extension of the previous models interdependent social networks are constituted in several layers to describe the particular features and intricate variability of each layer and investigate relatively independent dynamical process of each layer and identification of communities 34 36 however the heterogeneous property of individuals and networks are neglected in many previous researches and the influence on cooperation evolution owing to the multiplex nature of social networks and interactions is still an open question 37 it is necessary to investigate how the interlayer and intralayer interactions with heterogeneous property influence individuals behaviors and strategies especially when the cooperation emerges in multiplex networks in this work we will propose the heterogeneous diffusion model to describe and analyze the cooperation diffusion processes in diverse layers of multiplex networks so as to understand how the heterogeneous property of individuals and the multilayer nature of networks affect cooperation evolution the evolutionary game theory is generally used to stimulate the strategy behavior and interactions in interlayer and intralayer networks the work presents an exploratory study with certain theoretical innovation the rest of paper is organized as follows in section ii we present the heterogeneous diffusion model applied on the multiplex network with weighted values and corresponding method section iii provides some numerical experiments results to verify the model and reveals the influence of many heterogeneous properties of individuals and multilayer natures of networks on cooperation evolution processes in section iv the conclusions are given and some future works are suggested ii proposed model and method a heterogeneous properties of nodes most of previous research focused their models on the twolayered network in which each layer have same nodes and different layer means different connective relations however the real multiplex networks are more likely interdependent complex networks consisting of many communities and groups in which each layer may have different nodes and different topological structures it means that the heterogeneous properties of nodes and diversities of connective relations within same layer are one of outstanding characteristics of multiplex networks in addition the heterogeneity of degree distribution between nodes from interlayer networks will also affect cooperation processes and information spreading therefore considering the heterogeneous diffusion model on this type of multilayered network is more significant in the multiplex network the relations among nodes will be modeled as weighted edges to express the influence level of the heterogeneity of weight distribution on cooperation process there are different connective relations and weight distribution between and within layered networks in view of diversity of social networks the heterogeneous properties of social individuals and topology structures of network that affects cooperative dynamics include many factors such as social position of individuality contact degree distribution of nodes social influence force from authority groups and communities the trust level on neighbor nodes and other groups the strategy memory span of itself and so on moreover changes in the cooperation state of individuals will be also impacted by multiple neighbors from interlayer networks most of these heterogeneous characteristics of individuals and networks are essential for describing and understanding the processes of cooperation evolution and information diffusion in the real world b heterogeneous diffusion model to investigate the cooperation evolution processes from above dimensions and factors the heterogeneous diffusion model is proposed here firstly the multiplex networks with weighted values are generated randomly including the different nodes in each layer of networks the link degree of nodes on the intralayer and interlayer network as well as the weighted values of each edge then each node in each layer network will be fall into the authority groups and nonauthority groups according to its social position and influence force each of nodes with heterogeneous properties is defined as node e i w i k i sp i s i ml i if i rf i where e i denotes the set of all edges linking node i including intralayer edges and interlayer edges w i indicates the corresponding weighted values of all edges of node i k i represents link degree of node i including the links in the intralayer and interlayer network sp i is the social position of node i in the network s i delegates the current strategy value adopted by node i here two types of strategies are adopted in the social interactions that happen on interlayer and intralayer of networks cooperators and defectors two classical evolution games are performed in strategy interactions between individuals prisoners dilemma and snowdrift game 38 39 ml i is the memory length of node i storing former strategy values which express the impact of trust level on certain strategy if i represents the impacting force of strategy from the authority and nonauthority groups on node i while rf i is the reacting force of strategy from node i on these groups in this heterogeneous diffusion model for cooperation processes some heterogeneous properties of nodes in multiplex network could be further described expansively as follows sp i of each node mainly depends on the link degree of itself and the weighted values of all linked edges the social position of node i in network n1 is defined sp n 1 i ∀∈e n 1 w n ij m1 i1 ∀∈e n 1 w n ij volume 9 2021 where ∀ n i n j ∈ e n 1 indicates that there exist a direct edge between node n i and n j which belongs to the set of edges e n 1 in network n1 w ij denotes the weighted value of corresponding edge in the set for weighted values of all edges w n 1 and ∈ w n 1 according to the sp of all nodes in n1 the average value of sp can be obtained furthermore the network n1 can be divided into two groups the authority group g n 1 and nonauthority group g n 1 when the sp of node i is larger than the average value of sp it will be fall into g n 1 the nodes that its sp are smaller than the average value of sp will belong to g n 1 each node in the different groups may adopt different strategies in each time of cooperation interactions for each kind of strategies it is necessary to calculate their ranks that adopted in different groups according to the sp of all nodes and its obtained payoffs in each interaction ∀s rank i∈g n 1 s sp i × p i where the strategy s includes c and d g n 1 s indicates the set of nodes adopting the strategy s in the authority group g n 1 of network n1 p i is the payoffs of node i obtained by intralayer and interlayer interactions on basis of the evolutionary games obviously the ranks of different strategies adopting in two groups will be divided into rank rank rank and rank these four types of ranks should be calculated after each interaction to evaluate the influence degree between nodes for each strategy it needs to define the impact distance between node i and either of groups                    if i ∈ g n 1 d ig 1 × j∈g n 1 j i sp j j∈ g n 1 i if i ∈ g n 1 d ig 1 g× j∈g n 1 sp j j∈g n 1 here d represents the shortest weight path from node i to j and can be calculated by using the dijkstras algorithm in graph theory g is the number of nodes in the authority group g n 1 of network n 1 in the same way we have the impact distance between node i and nonauthority group d ig furthermore the impacting force of strategy s from the authority group g on node i is defined as follows if g s→i f σ 1 rank σ 2 d ig f σ 2 1 g × j∈g sp j × j∈g sp j × d where f is a function of monotone increasing σ 1 and σ 2 are two parameters to represent the relative importance degree similarly we have also four kinds of strategy impacting forces on node i according to different groups and different strategies adopted in these groups eg if g c→i if g d→i if g c→i and if g d→i obviously the weak impact of strategy from the nonauthority group is also considered simultaneously in the heterogeneous diffusion model the reacting forces of strategies from node i on these groups are not neglected since the node could obtain greater payoffs in the intralayer and interlayer interactions therefore the reacting force of strategy s from node i to the authority group g in network n1 is given rf g i→s g sp i × p i 1g s × j∈g s here g is also the function of monotone increasing in the same way four types of reacting forces rf g i→c rf g i→d rf g i→c and rf g i→d can be calculated c intralayer and interlayer interactions on basis of the evolutionary game rules node i will obtain the maximal payoff by playing the strategy interactions with the linked nodes from the intralayer and interlayer network as shown as p i1 and p i2 intralayer j1 p ij p i1 interlayer j1 p ij p i2 where k i is link degree of node i in the intralayer network while k n 1n 2 is crosslayer link degree of node i between network n1 and n2 here we use a crucial parameter α to adjust and reflect the tight degree of link relation between two networks then after once interactions of intralayer and interlayer the obtained total payoff of node i is p i αp i1 p i2 obviously the close interlayer interaction relation between two networks means that parameter α is smaller specially when α 1 it denotes that there are not any interlayer interaction relations between two networks since the parameter α reflects the interlayer interaction degree between two networks we still use the parameter to describe the probability for adopting the strategies from crosslayer network in other words a node will either adopt the strategy of group g n 1 and g n 1 in the same layer network with the probability α or adopt the strategy of a linked node in crosslayer network with probability after each strategy interaction for the latter the linked node j with the maximum sp j × p j in crosslayer network will be choose among neighbors nodes of number k n 1n 2 further if sp i × p i sp j × p j and s i s j the probability that node i will finally adopt its current strategy is i→j sp j × p j sp i × p i max k i k j × min here t represents the interaction moment while t and s are two parameters of game pd and sg in strategy interaction for the former when node i adopts the strategy of different groups in the same layer network some factors will have to be considered such as the impacting forces from different groups to node i and reacting forces from node i to different groups obviously the larger the if g c→i is and the smaller the rf g i→c is the node i is more inclined to adopt strategy c of the authority group in the same layer network here the ratio difference between if g c→i rf g i→c and if g d→i rf g i→d is used to describe the inclination in the interaction of time t 1 similarly the node i would also adopt strategy d of group g in intralayer network according to the ratio difference in addition a parameter β is used to indicate the influence degree from two groups to node i it means that node i will adopt the strategy s from the authority group g n 1 with the probability β and from the nonauthority group g n 1 with the probability the strategy that node i will adopt at next time can be defined as follows s i s g c if if g c→i rf g i→c ≥ if g d→i rf g i→d s g d otherwise s i s g c if if g c→i rf g i→c ≥ if g d→i rf g i→d s g d otherwise here s g c is the strategy c from g n 1 in intralayer network n1 at time t while s g c is the strategy d from g n 1 in n1 at time t in the proposed heterogeneous diffusion model the ml of each node is also an important property parameter which stores a series of former strategy values before time t the number of certain consecutive strategy in ml stands for the nodes trust levels on this strategy when consecutive identical strategy c occur in the ml of node and exceed the certain setting threshold strategy c will be adopted in next interactions of node otherwise the strategy update of node will conform to the above formula for interlayer interaction formula and for intralayer interaction in order to make the whole process of strategy transfer clearer a flowchart to show the sequence of each step is given to facilitate understanding as shown in figure 1 iii simulation results and analysis a experimental setup in experiment we focus on two factors the heterogeneous diffusion model and weighted multiplex networks all of multiplex networks will be randomly generated including the linked degree distribution of each node the corresponding weighted value of each edge and crosslayer linked edges with weighted values etc subsequently on the basis of the definition of each node in the model most of heterogeneous properties of nodes can be obtained according to the formula and such as sp if rf here two types of classical evolutionary games will be played in the intralayer and interlayer interactions pd and sg which are defined by four parameters r s t and p in the relative ordering and the range of specified values the games are played by pairwise interactions between nodes which are arranged either as cooperators or defectors the accumulation of payoffs on intralayer and interlayer network follows the same procedure and depends on the type of the social dilemma the pd game is characterized by the temptation to defect 1 t 2 suckers payoff 1 s 0 reward for mutual cooperation r 1 and punishment p 0 the sg game have 1 t 2 and 0 s 1 others are same as pd since r and p are fixed to 1 and 0 respectively s and t will be main parameters that analyze the densities of cooperation in each of interactions the nodes will adopt the two kinds of strategies c and d for each pair of t and s in their ranges of values 1000 twolayered weighted networks consisting of 1000 nodes in each layer are generated randomly including their interlayer link edges for each of duplex networks more than 10000 intralayer and interlayer interactions will be executed to update the strategies of nodes and verify the final stable state of cooperation evolution process finally for each pair of t and s the average cooperation densities of c are calculated and accompanied by different acrosslayer tight degree α and selected probability β of groups in the same layer meanwhile the nodes different strategy memory lengths ml another important parameter will be also analyzed figure 2 the average cooperation density distribution of c based on parameter t and s in their ranges when the game sg are played until cooperation evolution stabilizes 1000 twolayered weighted networks consisting of 1000 nodes in each layer are randomly generated for each pair of t and s the average density of c are obtained when the parameter that denotes the acrosslayer interaction tight degree between two networks α is 09 and α is 01 figure 3 the average cooperation density distribution of c based on parameter s and t in their ranges when the games pd are played until cooperation evolution stabilizes 1000 twolayered weighted networks consisting of 1000 nodes in each layer are randomly generated for each pair of t and s the average density of c are obtained when the parameter α is 09 and α is 01 b simulation results figure 2 shows the influence of the interlayer tight degree on the average cooperation density distribution of c when the strategy games sg are played in each interaction of intralayer and interlayer until the cooperation evolution process stabilizes here the probability β that selected the strategy from the authority group g n 1 in the same layer is set to 08 and the parameter α that denotes the acrosslayer tight degree between two networks is set to 09 and 01 respectively from the figure 1 it can be found that the densities of c are above 05 in some regions covering large t and small s specially there are higher densities of c in the regions of t ∈ 15 2 and s ∈ 0 05 furthermore the increasing rate of c is faster in these nearby regions when α 01 than when α 09 when α 01 there is very small densities of c in the regions of t ∈ 1 13 and s ∈ 05 1 just like when α 09 but in the regions of t ∈ 1 32 and s ∈ 0 02 the densities of c can reach to above 08 when α 01 and it is far higher than when α 09 it means that the tighter the interlayer interactions between two networks are the bigger the cooperation densities of c are in the nearby regions covering large t and small s as a whole there are higher c in most regions when α 01 than when α 09 which means the tight interlayer interactions can obviously improve the cooperation densities of c in the strategy games sg figure 3 shows the influence of the interlayer tight degree α on the average cooperation density distribution of c when the strategy games pd are played with the heterogeneous model in each interaction until the cooperation evolution process stabilizes it is obvious that the average densities of c obtained in games pd are usually lower than in games sg and the densities of c are less than 045 in most of regions based on each pair of t and s regardless of the interlayer tight parameter α specially the densities of c are close to 05 in the nearby regions of t ∈ 1 12 and s ∈ 08 1 when α 09 while the densities of c reach to about 05 in the regions of t ∈ 18 2 and s ∈ 08 1 when α 01 overall the average cooperation densities of c when α 09 are similar to that of c when α 01 which means the acrosslayer tight degree α has little impact on the cooperation evolution when strategy games pd are played it also means that the impacts of interlayer interactions are far less than the impacts of intralayer interactions in the games pd in the proposed heterogeneous model some properties of nodes will be influenced by the interlayer interaction tight degree α on the cooperation evolution a bigger value of parameter means the tighter acrosslayered link relation between network n 1 and n 2 here a case is further studied to investigate the impact of on the densities of c in which the nodes select the strategy from the authority group g n 1 in the same layer with probability β 08 as before the game parameters are fixed that t 12 and s 03 for sg and t 12 and s 08 for pd for each change of from 0 to 1 the stable densities of c are shown in the figure 4 in panel a it is obvious that the average densities of c only have slight increases from 035 to 042 along with increases from 0 to 08 when the interaction games are sg but when raises from 08 to 1 the average cooperation densities of c is significantly improved to 08 it illustrates that the interlayer interaction degree should be tighter as far as possible so as to obtain the greater effect on the cooperation densities of c in strategy games sg in panel b it can be found that the average cooperation densities of c have an obvious trend to descend along with increases from 0 to 1 when the interaction games are pd firstly the densities of c decrease distinctly from about 052 to 04 when increases from 0 to 02 then the densities of c keep decrease slowly to lower values this result is the opposite of strategy games sg since games pd is the harshest social dilemma for cooperation process it shows that only when the interlayer interactions tight degree are enough small in the pd game the effect of on the cooperation densities of c are more meaningful and noteworthy the above results could help to understand the deeper relationship between the interlayer interaction and the parameters t and s for the nodes linking the neighbors in other networks their payoffs are not only obtained by the interaction from intralayer network but also from interlayer network the larger this acrosslayer interaction tight degree the greater the probability of strategy diffusion across different network layer compared to pd game the suckers payoff s is positive in ranges of 0 1 on sg game the payoffs of interlayer linked nodes will be potentially observably increased due to crosslayer interactions so the tighter interlayer interaction has a more significant and profound impact on the cooperation densities of c on sg game than on pd game especially in some regions with larger t furthermore we also investigate the impact of another heterogeneous property on cooperation densities of c the strategy ml combining the interlayer interaction tight degree together as above mentioned the strategy ml means the trust level of nodes on certain strategies which are either from the groups in same layer or from neighbor nodes in acrosslayer network the figure 5 shows the combined effect of strategy ml and parameter on densities of c in some typical regions of different strategy games as shown in panel a it is apparent that the smaller strategy ml and the bigger interlayer interaction tight degree will obtain the higher cooperation densities of c when the strategy games are sg under a certain parameter the smaller the strategy ml are the higher the cooperation densities of c are with the increase of strategy ml the cooperation densities of c have an obvious trend to decline rapidly it illustrates that the nodes levels of trust in other nodes from certain groups highly influence the cooperation processes to some extent and the trust level of each node plays an important role on cooperation evolution specially when the strategy ml is 2 the average cooperation density of c reaches its maximum it can be understood that all of next strategy adopted by the node will be c if only the nodes previous interaction strategy was c in addition when the strategy ml is 1 it means that the impact of nodes trust on cooperation evolution will be not considered when the strategy games pd are played in intralayer and interlayer interactions the impacts of strategy ml on the densities of c are shown in panel b as a whole the densities of c are at relatively low levels and less than 04 in most of regions it is obvious that the densities of c have a smooth trend to descend with the increases of the strategy ml in despite of any interlayer tight degree it means that the selection of good strategy ml is more important for cooperation diffusion similarly the cooperation density of c reaches its maximum when the strategy ml is 2 it can be found that the impacts of interlayer interaction on cooperation processes are comparatively less in games pd than in games sg meanwhile the impacts of nodes trust on cooperation diffusion are also smaller in games pd than in games sg because of its smaller densities of c in summary the experimental results not only considered the main parameters in the classical evolutional games but also considered the impacts of nodes heterogeneous properties on cooperation densities of c the final results are obtained by iterating more than 10000 intralayer and interlayer interactions until stable in each different region of t and s and are stable average results based on 1000 randomly generated weighted multiplex networks it should be said that the results are already approximated final theoretical results since the final stable states of cooperation evolution process have been verified it is unlikely that there exists an approximated theoretical result of 1 or 0 covering all regions figure 5 a case studied on the impacts of the strategy ml property on cooperation densities of c under different interlayer interaction tight degree α in panel a the strategy games are sg when s 02 and t 12 in panel b the strategy games are pd when s 08 and t 12 the interlayer tight degree are 01 05 09 respectively to some extent the simulation results explore the cooperative evolution process in this weighted multiplex network by using the heterogeneous diffusion model and explore the influence of some important models parameters on the cooperation diffusion iv conclusion remarks this work focuses on the impacts of the social individuals heterogeneities and the multilayer nature of networks on cooperation evolution and proposes a heterogeneous diffusion model to describe and analyze the cooperation dynamics processes in diverse layers of multiplex networks with weighted values many heterogeneous properties of social individuals are considered and emphasized in the model including social position of node linked degree distributions of node in the same layer and acrosslayer networks the trust levels on neighbor nodes and other groups the strategy memory length of node the impacting forces of strategies from the authority and nonauthority groups on node the reacting forces of strategies from node on these groups and so on we investigated how the interlayer and intralayer interactions with these heterogeneities influence individuals behaviors and strategies especially when the cooperation emerges in multiplex networks we also discussed how some important and key parameters impact the cooperation densities and evolution processes in different strategy games two classical evolution games were performed in strategy interactions between individuals in this work prisoners dilemma and snowdrift game the results show that the tighter interlayer interaction can obviously improve the cooperation densities in the strategy games sg but has only little impact on the cooperation evolution in the strategy games pd the nodes trust levels on certain strategies from different groups play an important role in cooperation dynamics and highly influence the cooperation processes to some extent the impacts of nodes trust on cooperation diffusion are smaller in the games pd than in the games sg in addition the heterogeneity of degree distribution between nodes from interlayer networks also affects cooperation processes and information spreading but the impacts of interlayer interactions are far less than the impacts of intralayer interactions in the games pd the proposed model can well describe the individuals social heterogeneities and the multilayer natures of social networks and reflect their influences on cooperation evolution in interlayer and intralayer interactions of different strategy games in future work we will further search for some appropriate datasets of real multiplex social networks and expand our research into real scenarios for its application we will extend the proposed model and method to these networks and explore the mechanism and regular pattern of cooperation diffusion and information spreads considering the heterogeneities of individuals in real multiplex social networks and finally provide the governments with some supports to make rapid and precise decisions

cooperation evolution emerges in diversities of social networks by way of individuals interactions and influence propagations the influence on cooperation evolution owing to the multiplex nature of social networks and interactions is still an open question in this work we focus on the impacts of the individuals heterogeneous properties and the networks multilayer nature on cooperation evolution and propose a heterogeneous diffusion model to describe and analyze the cooperation dynamics processes in diverse layers of multiplex networks with weighted values we investigated how the interlayer and intralayer interactions with these heterogeneities influence individuals behaviors and strategies and discussed how some important parameters impact the cooperation densities and evolution processes in the interactions of different strategy games the experimental results show that the tighter interlayer interaction can obviously improve the cooperation densities in the strategy games sg but has little impact on the cooperation evolution in the strategy games pd the effect of individuals trust on cooperation diffusion is smaller in the games pd than in the games sg the heterogeneity of degree distribution between individuals from interlayer networks also affects cooperation processes this work explores and reveals the mechanism and regular pattern of cooperation diffusion considering the heterogeneities of individuals in multiplex networks with weighted values index terms cooperation evolution weighted multiplex networks heterogeneous diffusion model

19029_0

introduction adolescence is the period between childhood and adulthood this transition process is the cause of change so that teenagers feel more stressed in the process of adolescent development many changes occur in development fine motor and gross motor skills related to maturity or puberty cognitive intellectual social and emotional development incompatibility with adolescent development tasks will cause problems that arise such as antisocial behavior in adolescents drug abuse being easily moved into destructive behavior and falling into promiscuity such as smoking drinking alcohol brawls and sexual behavior one of the impacts of promiscuity is early marriage adolescents who are forced to marry or under certain conditions are under 18 years of age will be vulnerable to access to education health conditions and have the potential to experience domestic violence in indonesia itself nationally the trend of early marriage has increased due to the covid19 pandemic according to the ministry of national development planningbappenas there were 400500 girls aged between 1017 years carrying out early marriages from 20192020 during covid19 the percentage of early marriages in 2019 reached 1121 and in 2020 there were more than 64 thousand applications for marriage relief for underage children this figure is still categorized as high source based on table 1 above the research results showed that respondents knowledge about early marriage at sma n 1 doro before being given intervention was mostly in the poor category namely 71 respondents and in the good category namely 5 respondents knowledge after being given intervention was mostly in the good category namely 73 respondents and a small part was in the poor category namely 3 respondents so there was an increase in knowledge before the counseling was carried out and after the counseling was carried out by 895 based on table 3 it shows that the comparison of knowledge before and after being given the intervention there was a change the average before being given the intervention was 129 and after being given the intervention the average was 283 while the standard deviation before the intervention was 324 and the standard deviation after the intervention was 28 3 the statistical test results obtained a p value of 0000 so it was concluded that there was a significant influence before and after being given counseling using video media on knowledge about early marriage 4 it shows that the comparison of attitudes before and after being given the intervention there was a change the average before being given the intervention was 265 and after being given the intervention the average was 391 while the standard deviation before the intervention was 526 and the standard deviation after the intervention was 582 the statistical test results obtained a p value of 0000 so it was concluded that there was a significant influence before and after being given counseling using video media on attitudes about early marriage discussion knowledge or cognitive is a very important domain for the formation of a persons actions a persons knowledge about an object contains two aspects namely positive aspects and negative aspects in this study it was shown that the frequency value of the less category was 71 respondents this is because there are several factors that influence knowledge including education mass mediainformation social culture and economics environment experience and age the pretest results showed that knowledge was in the poor category as many as 71 5 in the good category after being given the intervention 73 respondents had good knowledge where the average knowledge before and after the intervention increased by 15 4 which means that after being given counseling knowledge increased from poor knowledge to good knowledge this increase in knowledge was influenced by the answers to the questionnaire which experienced a lot of improvement before being given counseling there were 961 of respondents the results of the posttest which increased according to martanegara revealed that knowledge and interesting media used in providing information can influence the increase in scores obtained from questionnaire questions this is in line with research conducted by fitriani that one of the successes of an extension can be influenced by mass media and presenters according to heriana good knowledge is obtained from the ease of obtaining information thereby speeding up a persons increase in knowledge this is also in accordance with research states that information is a source of a persons knowledge which will increase when they get a lot of information attitude is an assessment process carried out by an individual towards an object the process of a persons assessment of an object can be in the form of positive and negative assessments manifestations of attitudes cannot be seen directly but can only be interpreted first from closed behavior the pretest results showed that attitudes were in the negative category as many as 72 positive as many as 4 after being given health education using video media about early marriage there was a significant increase namely there were 12 respondents in the negative and positive categories were 64 martilova states that a persons attitude is influenced by beliefs emotions thinking tendencies beliefs and emotions which play an important role in a persons attitude human attitudes are not formed through social processes that occur during their lives where individuals gain information and experience this process can take place within the family school or community when a social process occurs a reciprocal relationship occurs between individuals and their surroundings these interactions and relationships then form patterns of individual attitudes towards those around them results of data analysis using the wilcoxon test for knowledge pretest and posttest a pvalue of 0000 was obtained so it is concluded that h0 is rejected and ha is accepted which means there is a significant influence before and after being given video media counseling on knowledge about early marriage this shows that counseling using video media can influence teenagers knowledge about early marriage at sma n 1 doro pekalongan regency the results of this study are in accordance with research regarding the effect of providing videos on the impact of early marriage in yogyakarta where a pvalue of 0000 was obtained so it was concluded that there was a significant difference between the control group and the intervention group video media is an effective medium in conveying information on reproductive health education counseling using video media increases teenagers knowledge of early marriage this is also in accordance with research which states that educational videos can increase the average knowledge from 5947 to 7831 the increase in knowledge occurs because the sense of sight will channel knowledge of approximately 7587 13 from the sense of hearing and 12 from other senses educational videos contain images and sound so that respondents are able to absorb around 88 of the information provided while emodules only contain writing and images so respondents are only able to absorb around 75 of the information provided results of data analysis using the wilcoxon test for attitudes pretest and posttest a pvalue of 0000 was obtained so it was concluded that h0 was rejected and ha was accepted which means there was a significant influence before and after being given video media counseling on attitudes about early marriage this shows that counseling using video media can influence teenagers attitudes about early marriage at sma n 1 doro pekalongan regency similar to research conducted by before and after being given the intervention there was an increase of 25 respondents seen from the pvalue of 000 which means there was a significant effect before and after being given counseling about early marriage factors that influence a persons attitude are personal experience the influence of other people culture mass media education religion and emotional factors attitude is a persons closed response to a stimulus or object and involves the relevant opinion and emotional factors health education is an application of educational concepts that aims to change detrimental behavior towards beneficial behavior the existence of health education for teenagers can gain better health insight and knowledge about early marriage videos are a substitute for the natural environment and can show objects normally videos can describe a process accurately and can be remembered easily so they can encourage and increase students motivation to keep watching them providing counseling using video media is an effective medium because at the time of the intervention several respondents had high enthusiasm for seeing the contents of video media shows attitudes will be formed when someone has been exposed to repeated information so that a positive attitude will be formed the results of this research provide important information about the influence of counseling using video media on adolescent knowledge and attitudes so that teenagers can prepare and understand the impact of marriage on themselves for their physical and psychological health the results of research using the wilcoxon test obtained a pvalue 0000 ≤ 005 which means that there is an influence of video media counseling on knowledge and attitudes about early marriage at sma n 1 doro pekalongan regency the limitation in this research is that it uses direct counseling using video media where the researcher must collect samples from the class this is because the researcher had difficulty collecting samples because at the time of the research it coincided with the students first day of school after the odd semester break so with help from the teacher more specifically it is the student affairs sector that collects samples so that researchers can carry out outreach conclusion based on the results of this research it can be concluded that the majority of 961 of respondents had good knowledge after being given counseling using video media most teenagers attitudes about early marriage after being given counseling using video media were in the positive category as much as 841 there is an influence of counseling using video media on knowledge about early marriage among teenagers at sma n 1 doro pekalongan regency there is an influence of counseling using video media on attitudes about early marriage among teenagers at sma n 1 doro pekalongan regency suggestions for institutions can use video media to increase students knowledge and attitudes about early marriage when providing education at school andor counseling guidance

early marriage is a phenomenon that appears among teenagers cases of early marriage are caused by external factors namely sociocultural environmental inappropriate media sources and lack of exposure to information about early marriage one way to increase teenagers knowledge and attitudes about early marriage is by providing health education through video media the purpose of this study is to determine the effect of video media counseling on teenagers knowledge and attitudes about early marriage at sma n 1 doro pekalongan regency the type of research used is preexperimental one group pretest and posttest design the sample for this research was 76 respondents from class this research obtained an average knowledge before 129 and after 283 the results of increasing knowledge before and after were 154 while attitudes were 126 the results of the wilcoxon test obtained p value 0000 005 which shows that there is an influence before and after being given counseling using video media about early marriage to teenagers at sma n 1 doro pekalongan regency conclusion it is hoped that related institutions academics and researchers can use video media as reference material in providing education about early marriage to increase the knowledge and attitudes of teenagers to avoid getting married at an early age

19030_0

introduction since the late 20th century people from all walks of life have gradually started to discuss the future community 1 in 1988 the american drucker foundation published the book the community of the future which proposed the beautifully imagined the community of the future 2 in 2000 roger fidler defined the community of the future by taking the development of new media as the starting point 3 in this context the future community was envisaged as a nexus where electronic media could enhance community intelligence by connecting community development and residents this perspective emphasized the role of electronic media in shaping the future community since then foreign scholars have gradually embarked on comprehensive studies of future communities ortiz robin constructed a green and public transportoriented new community transportation mode 4 the future countryside system the index system construction is not comprehensive the construction of the above evaluation index system is not systematic and does not solve the problem of what the theoretical basis for the construction of the evaluation system is since the commencement of chinas reform and openingup policy the chinese government has placed considerable emphasis on three rural problems concerning agriculture rural areas and farmers over the past four decades more than 25 no 1 central document policies have been issued spanning from the new countryside construction to the beautiful countryside initiative and presently the future countryside development phase despite entering this phase of future countryside development an observation from the current rural development status and the perspective of village organism systems in china suggests that the level of rural development has not yet reached the desired state therefore the following hypotheses are posited hypothesis 1 although rural areas exhibit the appearance of a proliferation of new buildings the overall development level remains suboptimal hypothesis 2 rural areas often display homogeneity and convergence in the competitive dynamics of rural construction hypothesis 3 socioeconomic and cultural aspects of rural development are characterized by uneven progress hypothesis 4 there exists a potential disconnect between the development of rural social systems and material spatial systems hypothesis 5 the topography and geomorphology of an area may impact the level of development within its villages from the perspective of the village organism system this paper seeks to ascertain the current objective level of rural development in china through the establishment of an index system for future countryside and empirical research the analytical approach employed in this system differs from conventional research methods featuring a systematic and somewhat innovative character theoretical basis 21 concept definition 211 cells of the village organism we call the space occupied by households and the people living in those households the cells of the village organism figure 1 sustainability 2023 15 x for peer review 3 of 23 international future community index system and construction guide 26 the index system highlights the characteristics of internationalization but due to the lack of research on the future countryside system the index system construction is not comprehensive the construction of the above evaluation index system is not systematic and does not solve the problem of what the theoretical basis for the construction of the evaluation system is since the commencement of chinas reform and openingup policy the chinese government has placed considerable emphasis on three rural problems concerning agriculture rural areas and farmers over the past four decades more than 25 no 1 central document policies have been issued spanning from the new countryside construction to the beautiful countryside initiative and presently the future countryside development phase despite entering this phase of future countryside development an observation from the current rural development status and the perspective of village organism systems in china suggests that the level of rural development has not yet reached the desired state therefore the following hypotheses are posited hypothesis 1 although rural areas exhibit the appearance of a proliferation of new buildings the overall development level remains suboptimal hypothesis 2 rural areas often display homogeneity and convergence in the competitive dynamics of rural construction hypothesis 3 socioeconomic and cultural aspects of rural development are characterized by uneven progress hypothesis 4 there exists a potential disconnect between the development of rural social systems and material spatial systems hypothesis 5 the topography and geomorphology of an area may impact the level of development within its villages from the perspective of the village organism system this paper seeks to ascertain the current objective level of rural development in china through the establishment of an index system for future countryside and empirical research the analytical approach employed in this system differs from conventional research methods featuring a systematic and somewhat innovative character theoretical basis concept definition cells of the village organism we call the space occupied by households and the people living in those households the cells of the village organism figure 1 village organism in a certain natural geographical space the cell cluster or cell collection formed by the gradual division and development of a single cell with a certain blood relationship and survival and development in a certain mode of production is called a village organism organs of the village organism the structural units that are composed of various tissues and have the function of coordinating certain social relations in the village organism are called organs future countryside future countryside represents the future lifestyle of the countryside and the ideal organism structure pattern corresponding to it basic theory village organism theory the theory of village organisms holds that a village is a living organism household is the most basic unit of a village just like other organisms village organisms also develop from the earliest single cell a person acts as a nucleus residing within a cell the nucleus carries cultural genes which constantly promote cell division and reproduction in the process of selfproduction of a human so that the organism with consanguinity develops and grows continuously and finally forms the village organism the growth of individual cells includes various life forms such as division reproduction death regeneration recombination and invasion structurally village organisms also follow the life structure of cell tissue organ and organism during the growth and development of village organic tissues cell functions begin to differentiate and some cell functions develop into organs of village organisms they take over or integrate certain management functions of individual cells in accordance with the principle that the whole is greater than the survival ability of individuals so as to realize the control of group cells and achieve the consistency of group cell cooperation according to marxs theory of social organisms the social organism contains five kinds of relations economy politics ideology consanguinity and ethics correspondingly we believe that the village organism has five organs economy politics ideology consanguinity and ethics which are respectively expressed in different spatial forms the five organs are in harmony with the relationship of metal wood water fire and earth in traditional chinese philosophy 16 the village organism is composed of a physical space system and a social system the physical space system is the space where people live and produce and the social system is composed of the social community living in this space and its lifestyle the social community is the living subject of the village organism and the physical space system is the carrier of the living subject this is reflected in the structural pattern shown in figure 2 the development of the village organism does not depend on the action of any one organ but is the result of the interaction between various organs therefore only the healthy development of the five functional organs can make the village live in a harmonious state all the five functional organs are indispensable their contradictory relationship promotes the growth and development of living organisms in villages yinyang theory yin and yang is a pair of categories in ancient chinese philosophy yinyang theory holds that the world is a material whole and everything in nature contains two opposing aspects of yin and yang and the opposing sides are unified yin and yang opposites yin and yang sympathies yin and yang push each other and finally maintain a balance the movement of the unity of opposites of yin and yang is the fundamental cause of the occurrence development change and extinction of all things in nature 27 yin and yang balance usually expressed by the taiji diagram means that things are in the healthiest state therefore for the ideal lifestyle and model structure of the countryside in the future we hope that the yin and yang balance all kinds of contradictions reach unity and the natural and social operation of the village achieve the most ideal state of balance this is the starting point of future countryside planning but also the fundamental goal of construction yinyang theory yin and yang is a pair of categories in ancient chinese philosophy yinyang theory holds that the world is a material whole and everything in nature contains two opposing aspects of yin and yang and the opposing sides are unified yin and yang opposites yin and yang sympathies yin and yang push each other and finally maintain a balance the movement of the unity of opposites of yin and yang is the fundamental cause of the occurrence development change and extinction of all things in nature 27 yin and yang balance usually expressed by the taiji diagram means that things are in the healthiest state therefore for the ideal lifestyle and model structure of the countryside in the future we hope that the yin and yang balance all kinds of contradictions reach unity and the natural and social operation of the village achieve the most ideal state of balance this is the starting point of future countryside planning but also the fundamental goal of construction scene theory according to barker environment and human behavior work in both directions and the two are ecologically interdependent units the material characteristics of the environment support certain fixed patterns of behavior and the fixed patterns of behavior are repeated over a period of time despite the constant change in users in the environment scene theory according to barker environment and human behavior work in both directions and the two are ecologically interdependent units the material characteristics of the environment support certain fixed patterns of behavior and the fixed patterns of behavior are repeated over a period of time despite the constant change in users in the environment which is called a place and the place and the behavior of the people together constitute the scene of behavior 28 therefore it can be understood that the physical space system and various social activities of people in a village are displayed in a certain scene we can dissect the village organism layer by layer according to the village organism theory to understand the scenes and connotations of the organism at different levels and finally construct and form the future countryside structure model construction of future countryside model and evaluation index system as can be seen from figure 2 the village organism is composed of a physical space system and a social system by analyzing the first layer of the two systems we can obtain the first level scene and its connotation and so on firstlevel scene construction physical space system the physical space system is composed of building space road space and green ecological space we strive to realize the lowcarbon operation of the physical space system therefore the three firstlevel scenes traffic scene building scene lowcarbon scene are used to represent the physical space system social system there are five social relations in the social system which are regulated by the five organs of consanguinity ideology politics economy and ethics a consanguineous organ is an organ that keeps the life of social organism young and coordinates the relationship between people in the village organism therefore it is represented by two firstlevel scenes neighborhood scene and health scene the political organ assumes the village governance function and is represented by the governance scene the economic organ assumes the production function and is represented by entrepreneurial scene ideological organ assumes the function of education and is represented by educational scene ethical organs undertake various functions of ethical and moral education and realize indirect education by constructing various public service facilities to meet peoples material and spiritual needs so it is represented by service scene secondlevel scene secondlevel scene is a further analysis based on the firstlevel scene traffic scene countryside transport includes passenger transport freight transport and transport therefore it is represented by three secondlevel scenes traffic travel tics distribution and parking lot lowcarbon scene secondlevel scene secondlevel scene is a further analysis based on the firstlevel scene traffic scene countryside transport includes passenger transport freight transport and static transport therefore it is represented by three secondlevel scenes traffic travel logistics distribution and parking lot lowcarbon scene lowcarbon scene includes a lowcarbon environment and lowcarbon life lowcarbon life is to reduce carbon emissions and improve the utilization of energy resources therefore it is characterized by three secondlevel scenes ecological green space comprehensive utilization of energy and resource recycling building scene the construction of village space includes the construction of buildings infrastructure and public space in countryside areas buildings are mainly built by private people considering the protection and utilization of traditional buildings they are represented by three secondlevel scenes characteristic style infrastructure and public open space neighborhood scene chinese traditional villages belong to the society of acquaintances and the interaction between people is a kind of warm affection and mutual assistance however with the weakening of village consanguineous relationships and the increase in migrant population the neighborhood relationship gradually weakens and needs to be reconstructed therefore it is represented by three secondlevel scenes neighborhood characteristic culture neighborhood open sharing and neighborhood mutual help life health scene the birth rate of newborns determines whether the village consanguinity can be sustained and determines the young state of life of village organisms the wellbeing index and life quality of villagers are determined by their health status and medical service level therefore it is represented by four secondlevel scenes newborn elderly health management home care and medical service governance scene village governance includes governance institutions governance mechanisms and residents participation the grid management model led by the party building has become the basic model of community governance and plays an important role in village governance therefore it is represented by three secondlevel scenes governance mechanism resident participation and governance platform entrepreneurial scene on the basis of traditional agriculture the current development of countryside industry mainly focuses on the development of the village collective economy the development of countryside characteristic industries new agricultural cooperative organizations the import of exogenous capital and other factors therefore it is represented by three secondlevel scenes village collective economy modern agriculture and new economy educational scene countryside education pays more attention to basic education for minors with the implementation of vocational education and the university for the aged education is developing towards learning opportunities for all therefore it is represented by three secondlevel scenes early childhood education primary education and knowledge at your side service scene countryside services are divided into village management services villagers daily life services and traditional moral education village management strives to build an information management platform the daily life services of villagers include the supply of various commodities traditional moral enlightenment is achieved by traditional handicraft artists through the construction of traditional building space and traditional artifacts so that people can attain intangible enlightenment therefore it is represented by three secondlevel scenes property integrated management platform commercial service and traditional handicraft development level evaluation index system on the basis of the secondlevel scene the specific content of the thirdlevel index factors is determined according to the actual situation of countryside areas the specific content of the thirdlevel index factors should reflect the characteristics of the future countryside therefore it should not only include the content of future industry and information management but also include the characteristics of countryside traditional cultural inheritance therefore traditional cultural elements should be reflected in the index construction such as the activation and utilization of traditional buildings characteristic traditional cultural projects village rules clan organizations traditional stove handicraft figure 4 clearly constructs the scene form and connotation contained in the future of the countryside through the analysis of four levels the deconstruction model of the future countryside is constructed and formed development level evaluation index system on the basis of the secondlevel scene the specific content of the thirdlevel index factors is determined according to the actual situation of countryside areas the specific content of the thirdlevel index factors should reflect the characteristics of the future countryside therefore it should not only include the content of future industry and information management but also include the characteristics of countryside traditional cultural inheritance therefore traditional cultural elements should be reflected in the index construction such as the activation and utilization of traditional buildings characteristic traditional cultural projects village rules clan organizations traditional stove handicraft artists etc reflecting the basic characteristics of urban and countryside integration jindong district of jinhua city is located in the middle of zhejiang province in the eastern section of jinqu basin with longitude and latitude between 119 • 14 120 • 46 east longitude and 28 • 32 29 • 41 north latitude the terrain is high in the north and south and low in the middle surrounded by mountains on three sides and sandwiched by a river the basin is scattered with three rivers are the basic features of the geomorphology of jindong district the climate of jindong district is subtropical monsoon climate with an average annual temperature of 175 • c an average annual precipitation of 15129 mm annual sunshine of 20505 h and a frostfree period of about 250 days there are obvious vertical differences in climate four distinct seasons abundant rainfall and rich water suitable for farming jindong district covers an area of 661 square kilometers with a total population of 507000 it has jurisdiction over two subdistricts eight towns and one township government and three hundred and fiftythree administrative villages after years of countryside construction and environmental governance in jindong district the aspects of village ecological protection village style transformation grassroots governance ability industrial development level and so on have been greatly improved it has been awarded many provincial honorary titles such as zhejiang provincial party committee and provincial government new era beautiful countryside model county provincial agricultural product quality and safety assured county provincial countryside household garbage classification and treatment winning county provincial african swine fever prevention and control model county selection of sample villages in the scope of jindong district 46 sample villages were selected the selection principle of sample villages first the principle of balance within the scope of jindong district 46 sample villages were randomly and evenly selected within each street and town based on the principle that the distance between villages and villages should be as equal as possible and the number of samples should be appropriate to the area of each town the second is the principle of data availability the selected villages should have a sound organizational structure and the village cadres should have a strong sense of the overall situation and be willing to cooperate with the research of this subject to ensure the availability of data selection of sample villages in the scope of jindong district 46 sample villages were selected the selection principle of sample villages first the principle of balance within the scope of jindong district 46 sample villages were randomly and evenly selected within each street and town based on the principle that the distance between villages and villages should be as equal as possible and the number of samples should be appropriate to the area of each town the second is the principle of data availability the selected villages should have a sound organizational structure and the village cadres should have a strong sense of the overall situation and be willing to cooperate with the research of this subject to ensure the availability of data data sources the data in this study came from field research based on the basis of determining the sample villages research methods and survey forms and with the support and introduction of the leaders of the jindong district land and resources administration bureau the research team members went to the villages separately to conduct field research and obtain firsthand survey data through interviews field measurements and other means research methods entropy weight method entropy is a physical quantity function that describes the disorder of molecules in the system the higher entropy is the more disordered the molecules are and the more chaotic the system is 29 the lower the entropy the more ordered the molecules and the more stable the system as an objective weighting method the entropy weighting method obtains index weights through the mathematical processing of sample data different from the subjective weighting method which relies on peoples subjective judgment the entropy weighting method has strong objectivity the concept of information entropy is a measure used to reflect the degree of disorder of the information system and measure the uncertainty of things the greater the information entropy is the more uncertain things are the more complex things are the higher the degree of chaos is let there be n cells m1 m2 an information source of mn and the occurrence probability of mi of each cell is p then the calculation formula of information entropy is defined as 30 h k ∑ n i1 p lnp in the formula k is the coefficient greater than 0 and 0 p 1 the smaller the information entropy the greater the available information and the greater the importance information entropy can be used to calculate the weight of each index the specific calculation steps of the entropy weight method are as follows dimensionless processing of data due to the difference in dimensionality and dimensionality units of different indicators it is impossible to directly compare the sample data so it is necessary to conduct dimensionless processing on the data in this paper the range transformation method is adopted to conduct dimensionless processing on the original data after dimensionless processing the index value is located in the interval 0 1 the larger the value of all indexes the better indicators can be divided into positive indicators and negative indicators the dimensionless formula of the positive index is y ij xij min max min the dimensionless formula of the negative index is y ij max xij max min data translation in the process of calculating the entropy value the logarithmic operation is required for the data here the standardized method is used to shift the data by one unit to avoid the situation that some data are meaningless when calculating the entropy weight after data translation it becomes as shown below so the normalized matrix is established yij y ij 1 calculation of the proportion of indicators pij represents the proportion of the index value j of the ith evaluation object in the total of this index the calculation formula is as follows pij yij ∑ m i1 yij calculation of index entropy this represents the entropy value of index value j the larger the entropy value is the greater the loss of information the smaller the entropy value is the less the loss of information and the greater the efficiency of information the calculation formula is e j 1 lnm ∑ m i1 p ij lnp ij calculation of index entropy weight this represents the entropy weight of index j and the index weight matrix is w the smaller the entropy of the index the larger the entropy the higher the importance of the index and the more important it is for the research object the calculation formula is w j 1 e j n ∑ n j1 e j after standardized processing of the original data from 46 villages the entropy weight method is used to calculate the entropy value of the index and finally the weight of each index in the complex village organism the various activities of the residents are complicated and the scenes are varied so the selected evaluation indicators are different using the entropy weight method to determine the weight of a certain index is one of the scientific methods and one of the commonly used techniques the fundamental difference between the index system in this paper and other evaluation models in the literature lies in the complete and systematic nature of the index system based on organic theory this index system systematically constructs various scenes of village organic social life the studies 17 18 19 only construct the index system from the perspective of development while the studies 20 21 22 23 24 25 construct the evaluation index system from the dimensions of construction status development potential cultural inheritance digital development etc respectively they are only some aspects or parts of the village organic system lifestyle so they are not systematic and complete enough to reflect the whole village organism topsis method topsis also known as the ideal point method is a multiindex decisionmaking method it was first proposed by wang cl and yoon ks in 1981 and has been widely used in performance evaluation it uses the distance between the evaluation value vector of the evaluation object in the research data and the ideal solution and the negative ideal solution in the comprehensive evaluation to judge the quality of the evaluation object so the evaluation objects are sorted if the index evaluation value vector of the research sample is closer to the ideal solution and further away from the negative ideal solution the performance will be better otherwise the performance will be worse 31 assume that there are a total of m sample data the number of evaluation indicators is n and the value of each evaluation index is the calculation steps of the topsis comprehensive evaluation method are as follows construct the weighted normalization matrix the weighted normalized matrix is constructed by combining the calculated index weights with the standardized data the maximum values of each index in the weighted matrix constitute the optimal solution vector x and the worst solution vector x respectively set the security normalization matrix as r and the calculation formula is r r ij m n y ij w j m n ideal and negative ideal solutions suppose the ideal solution vector is s r j 1 n and the negative ideal solution vector is s r j 1 n and the calculation formula is r j max r 1j r 2j r mj r j min r 1j r 2j r mj the distance between the index evaluation value vector and the ideal solution and the negative ideal solution suppose the distance between the evaluation value vector of the research sample index and the ideal solution is di and the distance between the negative ideal solution is di euclidean distance formula is used for calculation and the calculation formula is di ∑ n j1 r ij r j 2 di ∑ n j1 r ij r j 2 calculate the relative proximity ci between the index value of each evaluation object and the ideal solution ci d i d i rank the pros and cons of the evaluation objects according to the relative proximity the closer ci is to 1 the better the corresponding evaluation object is and the closer it is to the ideal health state of the village from the perspective of the village organism the closer ci is to 1 the closer it is to the ideal state namely the health state no matter the form and operation of the physical space system and the life state of the five organs in the social system assuming that the ideal state value of the yin and yang balance of the village organism is 1 the topsis comprehensive evaluation method aims to calculate the proximity ci between the status quo of social and economic development of each village and the ideal value according to the proximity the current development level of the village is determined the key to determining the objectivity and accuracy of the ci value is the selection and measurement of indicators in the process of multilevel analysis we hope to select the most appropriate scene in this study subjectively however objectively the index system cannot perfectly express the real operating state of village organisms so there are still some defects we hope to discuss with different scholars to further improve the index system in future studies the measurement of index data is also affected by various factors the error of measurement is inevitable and the measurement method needs to be further studied and perfected the selection of indicators is also affected by the regional cultural differences in the villages however the systematic structure of the village organism is the same regardless of the location they are made up of physical space systems and social systems therefore this study provides theoretical support and useful experience reference for how to dissect the organism and how to select the indicators division of health level based on topsis calculation results the health degree of sample villages in jindong district was evaluated comprehensively and in different dimensions a comprehensive evaluation is to evaluate the comprehensive health degree of villages in jindong district based on 46 evaluation indexes the subdimensional evaluation is to evaluate the nine scenes of the villages respectively in the health level evaluation the equal interval classification method in arcgis 32 was adopted to divide the relative proximity of 46 sample villages into five levels namely high health superior health medium health general health and low health the value range of ci is research results and analysis the current level of countryside construction is still in the lower middle level data show that the comprehensive health degree of all villages in the whole region is still at the lower level the average comprehensive health degree of all villages is 0346 among which the highest ci is 0486 and the lowest ci is 0230 this outcome corroborates the validity of hypothesis 1 despite chinas transition into the development phase of future countryside and the apparent proliferation of new rural construction the analysis from the perspective of the village organism system reveals that the development level is not ideal with each villages comprehensive development level still falling short of half of the desired value it can be seen that there is still a long way to go for chinas countryside revitalization convergence of competition among villages in countryside revitalization the study reveals that the comprehensive health status of the sampled villages is almost in the same growth trend line and there is little difference between the comprehensive health value of all villages and the median trend line this finding confirms the validity of hypothesis 2 suggesting the presence of competitive convergence during the rural revitalization process this indicates that despite the differences in development conditions geographical location resource endowment and development level all villages in the region actively carry out actions under the leadership and guidance of the government and form a joint force to tend to the same growth trend wellmotivated efforts to determine competitive position whether through brand positioning market research or other methods of competitive analysis end up being a baton that drives you toward a balance of power says youngme moon 33 this is also the fundamental reason why there will be a thousand villages are the same countryside revitalization as the governments work goal and brand positioning have become a baton for the current countryside construction therefore it is reasonable to see the convergence of competition which is also the fundamental reason for the emergence of the a thousand villages are the same the development level of villages in the mountainous and hilly areas in the north and south is lower than that in the central plain villages in mountainous and hilly areas in the north and south are generally lower than those in the central plain due to backward transportation conditions poor land and other resource conditions and serious population loss the overall development trend from low to high is mountainhillplain in the plain area the villages near the three jinhuayiwu expressways have the highest level of development the development level of villages in the mountainous and hilly areas in the north and south is lower than that in the central plain villages in mountainous and hilly areas in the north and south are generally lower than those in the central plain due to backward transportation conditions poor land and other resource conditions and serious population loss the overall development trend from low to high is mountainhillplain in the plain area the villages near the three jinhuayiwu expressways have the highest level of development in the central part of jindong district a profile is cut from south to north the health level of each village can be clearly seen by projecting the surrounding villages through the tangent line onto the profile showing a trend of high in the middle and low on both sides this outcome confirms the validity of hypothesis 5 emphasizing the substantial impact of topography and geomorphology on the development level of villages in areas with favorable topographical conditions villages tend to exhibit higher development levels whereas regions with unfavorable topographical conditions generally experience lower development levels among their villages in the central part of jindong district a profile is cut from south to north the health level of each village can be clearly seen by projecting the surrounding villages through the tangent line onto the profile showing a trend of high in the middle and low on both sides this outcome confirms the validity of hypothesis 5 emphasizing the substantial impact of topography and geomorphology on the development level of villages in areas with favorable topographical conditions villages tend to exhibit higher development levels whereas regions with unfavorable topographical conditions generally experience lower development levels among their villages the development level of villages in the mountainous and hilly areas in the north and south is lower than that in the central plain villages in mountainous and hilly areas in the north and south are generally lower than those in the central plain due to backward transportation conditions poor land and other resource conditions and serious population loss the overall development trend from low to high is mountainhillplain in the plain area the villages near the three jinhuayiwu expressways have the highest level of development in the central part of jindong district a profile is cut from south to north the health level of each village can be clearly seen by projecting the surrounding villages through the tangent line onto the profile showing a trend of high in the middle and low on both sides this outcome confirms the validity of hypothesis 5 emphasizing the substantial impact of topography and geomorphology on the development level of villages in areas with favorable topographical conditions villages tend to exhibit higher development levels whereas regions with unfavorable topographical conditions generally experience lower development levels among their villages the level of physical space system construction is higher than that of social system construction the results show that among the two systems of village organisms the health degree of the physical space system of each village is higher than that of the social system this outcome corroborates the validity of hypothesis 4 suggesting a disconnection between the development of the village organisms physical space system and its social system during the development process this phenomenon shows that in the process of new countryside construction and countryside revitalization in the past the government paid more attention to the external image construction of countryside society but ignored the internal function improvement of countryside society since xi jinping then secretary of zhejiang provincial party committee put forward the scientific conclusion that lucian waters and lush mountains are gold and silver mountains during his investigation in anji county huzhou city in august 2005 zhejiang province has carried out relevant rural construction actions in 2006 the new countryside construction of action in 2013 the five water treatment three reform and one demolition four sides and three modernization 811 environmental pollution remediation action in 2014 the construction activities of beautiful countryside boutique village and 3a tourism village were carried out in 2016 comprehensive environmental improvement of small towns was carried out in 2018 jindong district took the lead in establishing a pilot demonstration area for garbage sorting in china in these countryside construction activities the focus of local government work is basically on the construction of the countryside physical space system because these are surface projects easy to achieve results and easy to achieve political achievements however many endogenous problems of the countryside social system have not been the focus of local government of the physical space system of each village is higher than that of the social system this outcome corroborates the validity of hypothesis 4 suggesting a disconnection between the development of the village organisms physical space system and its social system during the development process this phenomenon shows that in the process of new countryside construction and countryside revitalization in the past the government paid more attention to the external image construction of countryside society but ignored the internal function improvement of countryside society since xi jinping then secretary of zhejiang provincial party committee put forward the scientific conclusion that lucian waters and lush mountains are gold and silver mountains during his investigation in anji county huzhou city in august 2005 zhejiang province has carried out relevant rural construction actions in 2006 the new countryside construction of action in 2013 the five water treatment three reform and one demolition four sides and three modernization 811 environmental pollution remediation action in 2014 the construction activities of beautiful countryside boutique village and 3a tourism village were carried out in 2016 comprehensive environmental improvement of small towns was carried out in 2018 jindong district took the lead in establishing a pilot demonstration area for garbage sorting in china in these countryside construction activities the focus of local government work is basically on the construction of the countryside physical space system because these are surface projects easy to achieve results and easy to achieve political achievements however many endogenous problems of the countryside social system have not been the focus of local government the health of the nine village scenes forms a grouping differentiation feature research shows that within the hierarchy of healthiness across the nine scenes of village organisms a distinct feature of grouping differentiation has become evident thus affirming the validity of hypothesis 3 this characteristic underscores the uneven development of various aspects within the village organism encompassing its social economic and cultural domains it signifies that the current efforts in the revitalization of the countryside exhibit not only a misalignment of focus but also areas of pronounced inadequacy in the first group comprising the construction of architecture lowcarbon and governance scenes substantial human and material resources have been invested by the government resulting in significant achievements however in the second group encompassing the construction of education health neighborhood service traffic and startup notable shortcomings have become apparent research shows that within the hierarchy of healthiness across the nine scenes of village organisms a distinct feature of grouping differentiation has become evident thus affirming the validity of hypothesis 3 this characteristic underscores the uneven development of various aspects within the village organism encompassing its social economic and cultural domains it signifies that the current efforts in the revitalization of the countryside exhibit not only a misalignment of focus but also areas of pronounced inadequacy in the first group comprising the construction of architecture lowcarbon and governance scenes substantial human and material resources have been invested by the government resulting in significant achievements however in the second group encompassing the construction of education health neighborhood service traffic and startup notable shortcomings have become apparent in the three scenes of the first group the comprehensive health degree ci of the building scene is 0486 nearly half of the ideal value on the one hand it benefits from the improvement of farmers income levels and on the other hand it benefits from the governments beautiful countryside construction campaign at the same time since the 18th cpc national congress a large number of traditional buildings have been repaired protected and activated the comprehensive health degree ci of lowcarbon is 0481 mainly due to the practical practice of the twomountain theory of lucid waters and lush mountains are gold and silver mountains and the high rate of natural gas to the household jindong district garbage classification is a demonstration area the comprehensive health degree ci of governance scene is 0452 which is mainly attributable to the governments emphasis on local governance and the innovation of countryside grassroots governance innovative measures such as party building alliance and grid management have greatly improved the level of countryside governance in the three scenes of the first group the comprehensive health degree 𝐶𝐶𝑀𝑀 of the building scene is 0486 nearly half of the ideal value on the one hand it benefits from the improvement of farmers income levels and on the other hand it benefits from the governments beautiful countryside construction campaign at the same time since the 18th cpc national congress a large number of traditional buildings have been repaired protected and activated the comprehensive health degree 𝐶𝐶𝑀𝑀 of lowcarbon is 0481 mainly due to the practical practice of the twomountain theory of lucid waters and lush mountains are gold and silver mountains and the high rate of natural gas to the household jindong district garbage classification is a demonstration area the comprehensive health degree 𝐶𝐶𝑀𝑀 of governance scene is 0452 which is mainly attributable to the governments emphasis on local governance and the innovation of countryside grassroots governance innovative measures such as party building alliance and grid management have greatly improved the level of countryside governance in the six scenes of the second group the comprehensive health 𝐶𝐶𝑀𝑀 of entrepreneurship scene is 0169 ranking the last the main reason is that chinas countryside land system still adopts the land contract responsibility system land resources are fragmented labor force and other productive factors continue to outflow modern agriculture the new agricultural business model has not explored a successful road the countryside collective economy is generally lacking and most of the countryside collective rely on government financial support so far the village organism still fails to realize the selfhematopoietic function and countryside economic development has become the biggest pain point of countryside revitalization the comprehensive health of the traffic scene 𝐶𝐶𝑀𝑀 0193 ranking the second from the bottom although there are buses in countryside areas there are fewer bus routes and a lower frequency which is difficult to meet the travel needs of countryside residents although the per capita ownership rate of private cars in countryside areas has been increasing construction land has been strictly controlled so there is a serious shortage of parking land in countryside areas vehicles can only be parked randomly and countryside express delivery and logistics are in their infancy the education scene is also grim in the process of urbanization a large number of countryside children in the six scenes of the second group the comprehensive health ci of entrepreneurship scene is 0169 ranking the last the main reason is that chinas countryside land system still adopts the land contract responsibility system land resources are fragmented labor force and other productive factors continue to outflow modern agriculture the new agricultural business model has not explored a successful road the countryside collective economy is generally lacking and most of the countryside collective rely on government financial support so far the village organism still fails to realize the selfhematopoietic function and countryside economic development has become the biggest pain point of countryside revitalization the comprehensive health of the traffic scene ci 0193 ranking the second from the bottom although there are buses in countryside areas there are fewer bus routes and a lower frequency which is difficult to meet the travel needs of countryside residents although the per capita ownership rate of private cars in countryside areas has been increasing construction land has been strictly controlled so there is a serious shortage of parking land in countryside areas vehicles can only be parked randomly and countryside express delivery and logistics are in their infancy the education scene is also grim in the process of urbanization a large number of countryside children flock to cities in search of highquality education resources and countryside education facilities continue to shrink which further depresses basic education in the countryside the vocational education of farmers has not been institutionalized and the university for the elderly only stays in the activity room stage the neighborhood scene is alarming the heterogeneity of the countryside population and the decline of moral level make countryside neighborhood relationship gradually estranged the health scene is not optimistic the aging of the countryside population the lack of medical resources the declining birth rate of children and the outflow of young people the service scene fails to meet the needs of villagers there is an unbalanced allocation of urban and countryside public cultural facilities and a shortage of various service facilities in countryside areas the construction of these six scenes still has a long way to go conclusions and discussion conclusions the village organism is composed of a physical space system and a social system and its structure has its own rules to study villages effectively it is imperative to adopt a systemic perspective treating the countryside as an interconnected entity encompassing various aspects commencing from the core of this organism a hierarchical analysis is conducted leading to the development of a structural model and an evaluation index system for future countryside research while different regions possess distinct cultural characteristics researchers should tailor their evaluation criteria to local conditions nonetheless the method of hierarchical analysis from an organism systems perspective holds a degree of universality despite chinas progression into the phase of future countryside construction it is essential not to be misled by the superficial phenomenon of new construction proliferation the overall health level of village organisms remains suboptimal signifying that chinas rural revitalization is still in its nascent stages consequently within the context of the grand rural revitalization project a mindset of preparing for a protracted struggle must be embraced the convergence of competition among villages in the process of countryside revitalization is the main reason for the phenomenon of a thousand villages are the same therefore improving the level of countryside cultural construction means that we should vigorously explore the connotation of traditional culture cultivate the countryside cultural brand of one village one product avoid homogenized competition in countryside competition rebuild cultural confidence improve moral level repair neighborhood relations and rebuild a harmonious acquaintance society in the process of countryside construction in the past the government paid more attention to the external image construction of countryside society but ignored the internal function improvement of countryside society therefore the government should change the performance view and behavior pattern we can lead countryside cadres and villagers out of a road of countryside revitalization with chinese characteristics only by changing the governments view of achievements eliminating the behavior pattern of grassroots cadres in countryside construction emphasizing the surface over the inner and shifting the focus of work to the cultivation of blood type countryside model countryside areas will have obvious weaknesses especially the village entrepreneurship which is the current pain point of countryside revitalization within the assessment of the nine major scenes the ci value is the lowest indicating that contemporary rural areas have yet to identify the optimal model for economic development therefore there is a pressing need to actively seek a rural modernization development model that aligns with chinas unique characteristics the small but natural economic model based on the land contract responsibility system cannot meet the needs of market competition the fragmentation of resources and results in brain drain and land wastage the establishment of a modern village limited liability company that can adapt to the incentive market competition environment by taking the road of collectivized development and expanding the collective economy may be a feasible way for countryside economy to get rid of the dilemma the healthy development of village organism is by no means a health problem of a system organ or scene all the organs in the system are connected with each other only by solving the weaknesses in countryside construction can the health level of village organism be improved as a whole therefore it is recommended to improve the level of infrastructure and public facilities the construction of a countryside transportation network improving the ability of countryside residents to travel there is also a need to improve the level of public construction in countryside areas and realize the balanced allocation of public facilities in urban and countryside areas the countryside education system requires reconstruction because countryside areas not only need to retain people but also to attract talents and constantly improve the level of farmer vocational education care for the physical and mental health of the elderly by improving the ability of countryside areas to cope with the trend of aging and make countryside areas a livable employable and tourist destination to truly realize countryside revitalization discussion there are several potential directions for future research firstly this study developed a model for the future countryside based on various theoretical frameworks including yinyang theory scene theory and village organism theory however the selection of indicators for evaluation was influenced by different regional lifestyles the construction of indicators in various regions was tailored to local circumstances following the principles of organism theory and the future countryside structural model involving a hierarchical analysis to choose specific indicators suitable for each locality the current indicator system construction is characterized by its regional specificity and there is room for further refinement the number of samples can also be appropriately increased in future research a more diverse set of sample villages will be selected utilizing the principles and methods of village organism system analysis combined with the local context certain indicators within the system will be replaced to enhance the scientific validity of village organism evaluation ultimately this will contribute to the broader applicability of organism theory and indicator construction and selection methods secondly countryside construction and sustainable development is a common concern at home and abroad to achieve sustainable development in rural areas it is necessary to uphold the planning thought and construction goal of yin and yang balance while focusing on the equilibrium between yin and yang in the village organism system attention should also be directed towards the microsystem equilibrium within each cell the equilibrium within the village organism system is achieved through the collective actions of its various subsystems therefore it is not only necessary to understand the deconstruction of the village organism system but also to delve deeper into the mechanisms of interaction among these subsystems and the inherent operational principles of each individual subsystem a thorough investigation of these issues requires a systematic and interconnected perspective only through such an approach can the sustainable development of the village organism system be realized lastly on the basis of the village organism theory future research can explore multiple directions such as investigations into cell activity within village organisms the study of the flow pattern of village organic volume study of the universal index and local index system of the future countryside index system examinations of the health degree of specific organs within village organisms and the development of more scientifically rigorous numerical analysis methods for the future countryside indicator system therefore building a future countryside model and understanding the evaluation system have an important impact on the future countryside construction and provide a new direction for the future countryside organism system research at home and abroad data availability statement the data presented in this study are available on request from the corresponding author

communities and villages are holistic organisms representing a complete system formed by natural space and human activities since the concept of future community was put forward by the drucker foundation in the united states at the end of the 20th century future community has expanded from the city to the countryside governments and scholars of various countries have started the practical and theoretical research into future community based on the theory of village organism this paper constructs the structural model of the future countryside and then constructs the health evaluation index system of the future countryside this effectively makes up for the shortcomings of previous studies and provides a new perspective and systematic analysis method for the study of community and village issues using entropy weight method and topsis method jindong district was used as a case to conduct the quantitative evaluation of the development level of 46 administrative villages in the region the results showed that 1 the development level of the villages in the region was not high and far from the requirements of future countryside indicating that countryside revitalization has a long way to go 2 within the region competitive convergence occurs in the development process of all villages 3 of the two major countryside systems in the future the health level of the physical space system is higher than that of the social system indicating that the local government pays more attention to the construction of the external image of the countryside and ignores the improvement of the internal function of the countryside society 4 in the prospective construction of nine scenes of future countryside an observable trend towards grouping differentiation emerges this phenomenon underscores existing deficiencies in countryside construction indicating that countryside areas still fail to realize the function of being selfhematopoietic the determination and selection of sample indicators exhibit regional cultural disparities permitting various regions to customize indicators with their specific contextual circumstances nevertheless the universal approach of treating countryside areas as holistic entities remains essential in scholarly inquiry

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background unmet need for modern contraceptives in subsaharan africa is high with an estimated 53 million of 89 million women in need of contraceptives 1 this need for contraception is often higher among young women in kenya in particular young people below the age of 25 constitute approximately 66 of the countrys population and often experience some of the poorest sexual and reproductive health outcomes 2 the kenya demographic and health survey of 2014 indicated that 18 of adolescent girls aged 1519 were already mothers or were pregnant with their first child 3 childbearing was reported to begin early in kenya with almost one quarter of women giving birth by age 18 and approximately half by age 20 3 contraceptive prevalence rate among sexually active unmarried girls aged 1519 years in kenya is 49 and 64 among those aged 2024 years 23 moreover the recent kdhs established that 12 of young women and 21 of young men aged between 15 and 24 years had their sexual debut before age 15 while 47 of young women and 55 of young men between the ages of 1824 years had their first sexual intercourse before their 18th birthday 3 the low prevalence rates of modern contraceptives coupled with early sexual debut increases the potential for unintended pregnancies among young women young women in ssa and kenya in particular are often deterred from using modern contraceptives because of limited access to contraceptive services poor quality of available services limited choice of methods fear of sideeffects cultural or religious disapprovals users or providers biases and genderbased barriers 45 additionally myths and misconceptions about the suitability of certain methods to particular audiences such as views by individuals and some healthcare providers that longacting methods are unsuitable for younger women contribute to nonuse discontinuation and low uptake of these methods by young women 6 increasing the level of contraceptive use especially the use of longacting reversible methods can have a significant impact on unplanned pregnancies largely affecting young women 7 moreover addressing contraceptive knowledge gaps and misperceptions can contribute towards improved contraceptive uptake among young women 4 a multivariate analysis examining associations between modern contraceptive uptake and belief in myths for individuals and communities in kenya nigeria and senegal found a negative association between belief in myths and contraceptive use in all the three countries in kenya the study found that a onepoint increase out of a total 8 points in the number of myths believed by a woman was associated with a 35 decrease in her likelihood of using any modern method furthermore kenya was found to have the highest proportion of men and women agreeing with family planning myths 8 similar concerns around longterm fertility impairment and dangers of prolonged use have been observed in both urban and rural kenya 9 comparably a crosssectional study in ethiopia determined that women who had no myths and misconceptions towards long acting and permanent contraceptives were more likely to use lapms compared to their counterparts who believed in contraceptive myths and misconceptions 10 most personal experiences of contraceptive use in kenya include iud injectables pills implants and male condoms 4 injectables however are the most widely used followed by implants and the pill across all sexually active women of different age groups and other demographic characteristics including marital status 3 despite prior research on contraceptive uptake associating male partners knowledge and attitudes towards modern contraceptives with womens contraceptive use 11 most of the studies in kenya focus on womens perspectives 12 few studies have captured the contraceptive narratives from young men and women in ssa and kenya in particular moreover young women between the age of 1524 face a significantly higher burden of unmet need for contraception compared to older women 1314 with little insights regarding their contraception perspectives therefore this qualitative study sought to explore and understand both young mens and womens knowledge of modern contraception and to identify key concerns regarding the use of contraceptives findings from this study will provide additional insights to policy makers and program managers in the design of appropriate age and gender specific srh interventions aimed at addressing unfounded contraceptive fears and misconceptions materials and methods study design and setting this is a qualitative study involving young people aged 1824 conducted in a periurban region of ukunda in kwale county kenya utilizing focus group discussion these fgds were part of a larger study 15 which used a randomized controlled trial to assess the effect of a mobile health intervention that provided sexual and reproductive health information to young people via text messages on their mobile phones in kenya and peru the fgds took place prior to the rct and aimed to confirm key myths and misconceptions around contraceptive use and common reasons for not using them the studys formative phase 16 included young people between the ages of 1524 but established that a majority of young people aged 1517 years did not own their own phones mobile phone ownership was an established eligibility criterion for this mobile health intervention study therefore for subsequent stages the decision was made to limit participation to those between 18 and 24 study procedures purposive sampling was used to select study participants residing in the study area resident enumerators in the larger digital health study were used to recruit study participants participants were identified based on their specific characteristics including participants ability to communicate their sexual life experiences in an articulate manner relates to the culture of the targeted community and their willingness to participate eligibility was based on age ranging 1824 years for both sexes literacy levels and being a resident of kwale county the ability to read and write regardless of any schooling level was considered for these fgds since participants were required to anonymously provide written responses prior to starting the groups discussions the individual responses explored independent thoughts from the participants which guided the discussions three interviewers were trained to facilitate the discussions and fgd activities they were provided with semistructured interview guides we conducted six fgds with 28 young women and 30 young men from kwale county we included an average of 10 discussants aged 1824 per fgd the discussions were held at the community social halls in kwale county and were facilitated by moderators of the same sex our fgds were dynamic with vignette and private writing activities to explore individuals and groups key myths and misconceptions around the use of contraceptives young people were asked to share what they knew about contraception with the following prompt tell me what contraceptive means or what you understand by contraceptive an additional activity asked participants to react first individually and then as a group to the following vignette vignette omar and his partner mwanakombo are talking about using family planning but they are nervous about what they have heard from friends what are some of the things they may have heard which could make them nervous after the moderator read the above vignette participants wrote their responses on large cardsan anonymous individual activity a second data collector gathered participants contributions and laid out the responses for the participants review each fgd group was then asked to discuss and select the most common concerns that young people in their community agreed with a semistructured discussion guide developed specifically for this study was used allowing the phrasing and focus of the questions on each topic and method mentioned by participants to be tailored depending on the group in addition to the vignette discussions young people in the study were asked to name and describe the kind of contraceptives theyve heard of and where people their age could get contraceptives additional discussions involved qualities of an ideal contraceptivedispensing unit specifically in nonclinical settings as well as what young people thought could be done to improve their contraceptive uptake all discussions were held in swahili and all proceedings were audio recorded with the participants consent data management and analysis the discussions were transcribed verbatim translated into english coded and analyzed thematically using nvivo version 12 two researchers read through all the six transcripts independently and held a session to discuss and agree on overarching themes a set of predefined codes reflecting the discussion guide as well as emerging issues was used in coding the qualitative data this was followed by a thematic coding framework in assessing the transcripts our analysis followed a pattern of association on the key preset themes focusing on awareness and myths and misperceptions around contraceptives awareness referred to ones ability to identify contraceptives without necessarily understanding how the contraceptive works myths in this study refer to misinformation and widely held but false beliefs about contraception that differ from womens concerns regarding documented or experienced methodrelated side effects finally misconceptions are defined as specific and widespread beliefs about the effects or purpose of contraceptives that are not supported by any scientific evidence 6 our analysis and findings are presented in accordance with the consolidated criteria for reporting qualitative research 17 ethical considerations ethical clearance was obtained from world health organization institutional review board and the kenyatta national hospitaluniversity of nairobi ethics and review committee all participants gave written informed consent to participate in the study results among youth participants 567 of male respondents reported to have completed their secondary education compared to 286 of females when disaggregated by age and sex groupings the proportion of females in dating relationships was relatively high compared to their male counterparts in this study those dating or reported as friends with benefits referred to a participant who had a regular sexual partner with whom they enjoyed spending time without any formal agreement to marry married or engaged on the other hand was reported by those with sexual partners and in unions with formal marital arrangements there were more muslim female participants than christians by contrast all male participants were muslims this study was done in kwale county where the digo community who are predominantly muslims are the majority this explains the higher proportion of muslim participants in the study results are presented under four key themes awareness of contraception myths and misconceptions around contraception males contraceptive narratives and young peoples preferred sources of contraceptives awareness of contraception when asked to explain what they understood by contraceptives both males and females reported awareness of contraceptives with some providing a combination of descriptions andor listing of the methods injections and the intrauterine device were the most frequently identified contraceptives other methods mentioned included condoms withdrawal and rhythm method of birth control it was clear that young people knew or had heard about contraceptive methods but had minimal knowledge on how they actually worked there are injections that you can use i dont know how to explain it to you there are injections when one uses it will just help you to family plan there is something i have heard but im not familiar … with a coil when you get to a hospital you get the coil … they put coil to women compared to young men young women were more aware of contraceptives in that not only did they list the contraceptives but also went ahead to explain the perceived duration of effectiveness of some methods like the injection and implant to add more on the injection there is an injection that someone can have for 3 months and there is the implant … which is put here for 5 years myths and misconceptions around contraception male and female participants shared several myths and misconceptions around contraception some respondents mentioned that the use of contraceptives jeopardized future fertility and could lead to serious health complications such as prolonged menstrual bleeding problems conceiving and birth defects the most common misconception among both male and female participants was the perceived infertilities mistakenly associated with contraceptives hearsays from peers about perceived side effects and misinformation came out strongly in both male and female fgds this finding might explain albeit tacitly young peoples source of contraceptives myths and misconceptions people say that when you get the injection and if it does not work well for you you bleed you will bleed until you cannot get pregnant again and give birth you will just be bleeding and bleeding there are people who bleed for many months because of those injections if for example you want to use theafterthreemonths injection they say that if you use it often then time comes and you want to stop using it and you want to get pregnant you may wait for ten good years or forever and you will not get a baby at all because … i dont know it makes the egg to get lost and it becomes weak that is what it means by destroying the womb when they have used contraceptive to prevent them from getting pregnant if a man and a woman maybe in some years to come they will have stopped using them and they now want to have children some of them will be born with abnormalities not as usual children but deformed and underweight participants also reported fears that iuds could be pushed inward during sexual intercourse and damage the womens reproductive organs this came from the belief that the perceived discomfort during sexual intercourse inaccurately believed to be experienced by users of iuds is as a result of the iud moving out of its normal position thereby making it exposed during sexual intercourse i heard about the coil that coil is inserted here in the womb the time you are having sex with that person and he pushes it inside already he would have messed up everything it will force you to remove it mens contraceptives narratives men in the study had their own strong concerns about adverse sociocultural effects of contraceptives several of these related to sexual relations between couples and sexual desire some reported that contraceptives contribute to decreased sexual desires among women forcing men into infidelity other negative effect is that it breaks marriages because those drugs lower womens sexual feelings so if you were used to like four sex rounds a week this will reduce to two times it will be a must for you to go outside you will not agree somewhat counterintuitively contraceptives were also perceived to contribute to infidelity on the part of women as a result male respondents worried about the effect of contraception on the trust in a relationship this was seemingly because with reduced risks of getting pregnant young men thought that their women will increase their sexual frequency and with more partners this goes further to explain the contraception confusion displayed by young men while others opined that contraceptives would decline their sexual rights due to their womens reduced sexual desires their counterparts in the same age group had contrasting beliefs relating to the sexual effects of contraceptives we have trusted one another and the wife takes those contraceptives and prevented herself from pregnancy there will be no trust between us because one knows that she can have sex with anyone from outside and not getting pregnant so i will not trust her in short it means untrustworthiness because you cannot get pregnant … so maybe you will be having sex with someone or feel free to have sex anyhow and thereby infecting your partner with sexual diseases interestingly male participants also perceived that contraceptive methods deny couples their sexual freedom and regarded them as an unnecessary burden respondents were concerned about the implied prerequisite of always attaching contraception to sex perceiving their sexual lives to be enslaved to contraception thereby taking away the pleasure of having sex i see it as slavery using them because it will be you and your wife at home and the time you do the marriage act you will be wearing trust and then using drugs every time you cannot skip if you skip it will be a problem when you say that you are leaving them also it is a problem again every time you will be going to the hospital or going to the chemist and take drugs as in a burden something like that among additional sociocultural concerns young men in the study also expressed beliefs that it was against african traditions to not want children first of all in africa many africans perceive contraceptives as unafrican … in the african communities children are important … if someone avoids getting a child … the first year no child second year no child … husband will now start to worry … and due to that the woman will be divorced finally young men confused abortion and pregnancy prevention methods with some participants mentioning that contraceptives could also be used to terminate pregnancies some young men in the study reported that by preventing natural pregnancy progression after unprotected sex emergency contraceptive pills served to end an existing pregnancy it was also established that some participants in the men fgds couldnt tell the difference between emergency contraceptive pills that prevent pregnancy after unprotected sex and abortion pills that terminate an already existing pregnancy contraceptives are things which prevent one from getting pregnant or if one wants to abort when she has been impregnated by a man this confusion resulted in some participants feeling contraceptives were a curse you can say it is a curse because it is like doing murder you will have killed you can get a curse from god because you are not allowed to kill another for any mistake young peoples preferred sources of contraceptives although pharmacies and public health facilities were the reported common sources of contraceptives among the respondents there was no consensus as to where young people would prefer to go for contraceptives both male and female respondents expressed varied preferences and dissatisfactions with the two contraceptive sources these variations ranged from lack of privacy at the public hospitals attitude of the healthcare providers to the cost associated with getting their preferred methods some respondents preferred pharmacies to public facilities because of their privacy nature the goodness of the chemist is that there is privacy because everyone who sells at the chemist is not known to you but you can go to the hospital and you happen to find relatives who might see you now when you go to the chemist one is not asked what they are going to buy being served by people their age was a reported factor that made pharmacies appeal to young people moreover respondents reported that pharmacies are the preferred sources of contraception because the pharmacies personnel were considered polite and welcoming as opposed to the reported attitudes displayed by healthcare providers at the public health centres then another reason is that most of those attendants at the chemist are age mates so when you get there you can express yourself in details and heshe will understand you unlike at a hospital where you will find an old person is the one serving people as my colleague had said you can get a harsh person at the hospital but when getting to the chemist most of them talk politely and welcoming the customers they have good language conversely and unlike in the previous themes where participants acknowledged and almost approved their colleagues assertions about contraceptives the preferred sources presented dissenting opinions public hospitals were instead considered ideal by a section of the respondents who opined that unlike pharmacies public hospitals provided better and professional services and at an affordable cost also at the hospital the services are cheap as compared to places like chemists you see the hospital might be a government hospital so what heshe needs might be cheap compared to other centers there is better treatment at the hospital compared to these chemists for example if the service provider is a form four leaver he will not understand anything but at the hospital they are good and educated nurses and doctors discussions most respondents in the fgds were aware of contraceptives nonetheless findings from this study confirmed that awareness does not translate to accurate knowledge of contraception and how it works we also identified key myths and misconception that young men and women have against modern methods of contraception additionally we described specific sociocultural perceptions exhibited by men respondents in the study which could influence their and their partners acceptance and use of contraceptives finally we looked at preferences put forth by young people when choosing where to seek contraceptives services uncertainties about side effects play a key role in young peoples disapproval of the effectiveness of modern contraceptives in kenya 4 unsubstantiated fears about contraceptive safety can lead women to either forgo contraceptive use opt for less effective methods or even use effective methods incorrectly hence further jeopardizing their overall health 6 consistent to these findings is a qualitative study on barriers to modern contraceptive uptake among young women in nyanza coast and central regions of kenya which established that myths and misconceptions were a major barrier to contraceptive uptake and that individuals beliefs about the effectiveness of contraceptives were dependent on social approval by their peers 4 the negative perceived effects of modern contraceptives will ultimately contribute to the low uptake if information about modern contraceptive methods continue to be misrepresented 18 misconceptions around future fertility later in life seem to create fear in both young men and women prevalence of such myths and misconceptions have also been demonstrated to be existing among young men and women in other studies and national surveys 3611 18 19 20 these studies and national surveys established that the perceived interference with future fertility was the main barrier to modern contraceptive uptake among young women determining the actual magnitude effect of these myths and misperceptions remains a daunting task as most quantitative studies fail to distinguish womens concern about documented side effects from unsubstantiated fears about adverse health effects 6 few studies have also attempted to describe the factors contributing to support of modern contraceptive use among sexually active men 12 in this study young men perceived contraception use to have the potential to create conflicts within marriages and a possible spike in sexually transmitted infections this was tied to a perception that because women no longer need to worry about pregnancy the only perceived evidence of a sexual act for womenthey would be inclined towards promiscuity in nigeria it was found that mens perceptions that contraceptives are enablers for promiscuous behaviors among women was negatively associated with the use of modern contraception among their female partners 21 mens lack of trust towards their female partners has been shown to be a major driver of misconceptions associating contraceptives with promiscuity 421 the fact that these concerns were held by male participants underscores the importance of engaging men in addressing low contraceptive uptake in kenya male partners opposition was identified as one of the key factors contributing to contraceptives discontinuation tendencies 5 similarly in an analysis of 20052009 demographic health survey data from 21 african countries it was established that gender norms and gender inequalities in the community were among the potential contributors to uptake or nonuse of contraceptives 1822 men therefore need to be adequately involved and informed about contraceptives and their effects as they remain important decision makers in contraceptive use 12 as such a critical strategy to reduce misinformation and increase uptake of contraception among young women is to increase avenues where young women and young men can get credible srh information both national and county governments in kenya and other ssa countries need to provide technical support and supervise the implementation of youthfriendly service interventions in public health facilities for srh services to be effective to young people there is need for high quality reproductive health products information and services increased points of accessing srh services for young people as well as provision of continuous health education including comprehensive sexuality education to help them win the war against societal taboos associated with srh seeking behaviours 1318 other figures in young peoples lives can also play an important role in normalizing their use of contraception this study has established that a section of young people perceived pharmacies personnel as better placed to offer friendly contraceptive services compared to the public health facilities with improved regulations and control of pharmacy services in kenya provision of contraception through pharmacies can help address significant barriers associated with young peoples contraceptives uptake 23 there is also evidence for example that parentyouth communication on srh is associated with young peoples improved use of contraceptives 24 interventions which include parents and promote increased discussion within families therefore provide another interesting opportunity with the potential to see significant positive influence on young peoples sexual attitudes value and beliefs regarding modern contraceptives 2526 in general there is a need to push and advocate for the design of multilevel programs and interventions targeting young people particularly young men with srh information for young men in particular this entails going also to where they already gather outside the home including youth camps in churches and mosques or popular media programs targeting young men in kenya like man enough and man talk using these as information dissemination channels can contribute to helping young men to understand their srh roles and be well informed for them to act both individually and collectively to empower their female partners while improving their own srh behavior moreover srh communication programmes should focus on changing contraceptive norms among adolescent boys and girls before misconceptions set in 6 in addition to early comprehensive sexuality education one solution to reach young men and women as determined by several studies is via direct client communication using a digital health interventions 27 28 29 30 31 the focus for effective media should be on providing correct information as opposed to negating the myth while keeping the information simple with a compelling explanation to replace the existing myths and misconceptions 6 study strengths and limitations one significant strength of this study is in the way the fgds were conducted where indepth thoughts were first explored independently through vignettes using an anonymous individual activity this individual reaction by study participants prior to the group discussions allowed each group to focus on issues they considered the most common in their community this approach provided an expansive method in the analysis of views and feelings considered relevant in this study this study had certain limitations young people may have felt uncomfortable sharing their views on contraception particularly if they were not confident in their knowledge moreover they may have been uncomfortable or embarrassed to share myths and misconceptions particularly if they felt unsure as to whether these were shared we attempted to mitigate these by providing opportunities for participants to make individual contributions to the discussion in addition the use of vignettes allowed participants to place any mythsmisconception on a fictional third party another limitation might be the eligibility criteria limiting participants by literacy levels however according to the kdhs of 2014 3 literacy rates among 1524 year olds in kwale was more than 95 a significant majority of young people in kwale county can therefore read and write conclusion this study contributes to the larger literature on young peoples myths and misconceptions preventing them from using modern contraceptives overall these findings are consistent with other studies in ssa which imply that improved srh literacy must include explicit attention to lingering contraception myths and misconceptions additionally efforts to address srh myths and misperceptions need to employ multifaceted approaches at both individual and community levels finally genderspecific interventions to specifically reach out to young men with factual srh information aimed at dispelling contraception misconceptions may go a long way towards making young men educated about and supportive of their partners choice to use contraception data collection and analysis and this manuscripts development were led by the firstcorresponding author and the rest of the international centre for reproductive health kenya team the firstcorresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication competing interests the authors declare that they have no competing interests

background myths and misconceptions around modern contraceptives have been associated with low contraceptive uptake in subsaharan africa and kenya in particular addressing persistent contraceptive knowledge gaps can make a significant contribution towards improved contraceptive uptake among young women this qualitative study therefore sought to explore and understand young peoples knowledge of modern contraception and to identify their key concerns regarding these methods methods we used focus group discussions fgd with vignette and writing activities to explore key myths and misconceptions around the use of contraceptives six fgds three for young men and three for young women were conducted with a total of 28 young women and 30 young men from kwale county kenya we included 10 discussants aged 1824 per fgd one fgd had 8 participants predefined codes reflecting the discussion guides and emerging issues in the fgds were used to develop the thematic coding framework our analysis followed a pattern of association on the key preset themes focusing on myths and misconceptions around contraceptive use results results are presented under four key themes awareness of contraception myths and misconceptions around contraception males contraceptive narratives and young peoples preferred sources of contraceptives both men and women participants reported basic awareness of contraceptives a mixture of biological and social misconceptions were discussed and included perceptions that modern contraception jeopardized future fertility could result in problems conceiving or birth defects made women promiscuous was unafrican and would deny couples their sexual freedom compared to female respondents in the study young men appeared to be strong believers of the perceived sociocultural effects of contraceptives on preferred sources of contraceptives respondents reported on two main sources pharmacies and public hospitals however they could not agree on which one was suitable for them

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introduction as the prevalence of social media in the world around us increases and the number of users on these online platforms grows so too grows the rate at which scholarly content is being proliferated and discussed in these venues more and more academics are finding it rewarding to look to these platforms for the insight they provide into research problems one reason scholars have turned to social media is to measure the influence their work is having in those spaces this has become known as alternative metrics or altmetrics 1 another reason is for permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page copyrights for components of this work owned by others than acm must be honored abstracting with credit is permitted to copy otherwise or republish to post on servers or to redistribute to lists requires prior specific permission andor a fee request permissions from acmieee june 2019 urbanachampaign illinois usa © 2019 association for computing machinery the knowledge online platforms provide about human behavioran area of research known as socialmedia analytics 369 studies in socialmedia analytics tend to focus either on text using approaches such as natural language processing sentiment analysis or opinion mining to arrive at and support research conclusions 12 or on the proliferation of content through online communities 5 these approaches have proved effective for understanding or predicting many aspects of human behavior but they leave a number of other expressive signals unexamined clickbased reactions on the other hand are a relatively underutilized resource in socialmedia research examples of quickdraw readymade expressive features are becoming increasingly prevalent across many platforms and as such have attracted some amount of attention from researchers in the past few years 24 in this paper we present a new dataset of clickbased reactions to scholarly articles on facebook and use it to gain insight into how users are interacting with scholarly articles on that platform in addition to information about the articles themselves our dataset records the count of each clickbased feature we could access through facebooks graph api we use our newly developed dataset to train and test two machine learning algorithms and our analysis of the results shines some light on surprising relationships between features building the dataset before going any further it will be useful to define a few terms and features • clickbased reactions nontextual user interactions with shared contentsometimes referred to simply as reactions includes facebook likes and reactions reshares and page visibility • reactions the five clickbased reactions love amazed laughing sad and angry will be distinguished from the common term reaction by capitalization • page visibility the number of followers a facebook page has • reshares the number of times users have reshared a public post of an article into another location the roots of our dataset lie in the online resource altmetric 1 which tracks the impact scholarly articles have across a variety of social media platforms we used altmetric as a jumpingoff point querying their api 2 for information on articles we were interested in and for the public pages onto which they had been shared it gave us access to the titles publication dates subjects and the urls of facebook shares for nearly 15 million scholarly articles we targeted content shared on facebook rather than other socialmedia platforms for several reasons first facebook offers its users a variety of clickbased interactions with which they can personalize their response to content other platforms we considered targeting such as twitter have more limited palettes of clickbased reactions available to users second facebooks enormous population of active users increases the likelihood that content shared there will receive more attention it has about 227 billion active monthly users almost seven times twitters active population of 330 million third the impact of scholarly articles on twitter users has been the subject of many recent studies 5811 whereas the response to this type of content on facebook remains largely unexamined with our list of facebook urls for article shares we queried facebooks graph api 3 for the reaction counts on each post our dataset records their responses and was collected during the period of december 113 2018 constraints in the number of queries allowed by facebooks api determined the rate at which we could work the resulting dataset is publicly available on osf 4 as a commaseparatedvalue file we limited our collection efforts only toward scholarly articles published in 2017 choosing this year accomplished three goals reactions were released by facebook in february 2016 7 so any articles we looked at had to be published after that time to have meaningful data on this feature any time a new feature is unrolled it takes some amount of time for users to learn how to use it prah 10 finds that use of reactions increased from 24 of all interactions in april 2016 to 58 by june 2016 and up to 128 of all interactions by june 2018 by the time of our data collection in december 2018 a large enough subset of users were comfortable expressing themselves with the feature to warrant more scholarly attention and by the time we began our data collection a sufficient interval of time had passed for articles to be widely shared and reacted to of all the articles tracked by altmetric we found 296052 were published in 2017 and had been shared on facebook at least once we eliminated entries that were missing data on the pages to which the articles had been shared this reduced our set to 135635 articles we further limited the scope by selecting only articles with scopus 5 subjects in the scientific domain we chose to focus only on articles in the health sciences physical sciences social sciences and environmental science figure 1 shows that these four categories article counts fall within one standard deviation of the mean number of articles as do the total number of facebook shares it also displays the full list of subjects in all the 2017 articles and gives a sense of their distribution the mean and two standard deviations are indicated there with blue lines for both axes and the four subjects we target are indicated 2 3 4 5 with arrows in the plot limiting the scope of subjects reduced the number of articles needed to process to just over 31000 when we removed articles with missing features such as abstract and title we were left with 11474 articles these are the articles recorded in our dataset in our data collection process we took the utmost care to respect altmetrics and facebooks specifications for how and why their data can be accessed and used and to protect the personal information of socialmedia users our interests are only in the ways that people are interacting in the aggregate with scholarly content on social media platformsnot in specific ways users beliefs or opinions may influence their behavior we recognize that identifying information could in some instances be inferred a posteriori from some of the data we collect however our method of data collection does not target anything that could be used to consistently identify individual users and avoids collecting identifying information about individuals data exploration the clickbased features of our dataset are displayed along the axes in figure 2 also displayed are the pearson r correlation coefficients for all feature pairs highly correlated pairs are like and love sad and angry like and amazed love and reshares we can infer that high positive correlation is a sign that users employ features in similar contexts and that the emotional expressions represented by those features overlap for example a like seems to have a meaning comparable to a love or an amazed or a laughing reaction these relationships may not surprise us because they are all positive emotional states but other feature pairs that have related expressive values in usage such as angry and sad reactions are not so intuitive likes and reshares are correlated with the most other features this might be explained by the fact that these two are the oldest reactionsbut we also notice they are correlated with other emotionally positive reactions such as love or amazed and not with the negative emotions sad or angry it follows that by liking or resharing a post a user expresses a positive emotional reaction to its content looking at this from another angle we infer that content that is more likely to inspire a negative reaction from users is less likely to be reshared or liked high correlation between features can lead to increased variance in model results to counter this modelers often eliminate one of a pair of correlated features rather than removing features and losing data in our sparse dataset we combined lovewow and sadangry reactions into two new composite features for our models low correlation signifies that features have relatively distinct use values among the lowest r coefficients are loveangry and laughingsad this makes intuitive sense as these reactions nominally encompass opposite emotions laughingpage visibility is another lowcorrelation pair suggesting that articles that inspire humor are more likely to be posted to public pages with relatively low follower counts it is likely that this relationship may be a result of our choice to limit the articles we include to those in the scientific domain where humor is an underutilized affect our dataset also contains outliers in each feature category to correct for these we rescaled the features to a range from 0 to 1 then took the cube root to these new values our root normalization function is demonstrated in equation 1 it helped to smooth the distribution of values raising the lower values by more than it raised the higher values the result after combinationnormalization is displayed in figure 3 rtnorm 3 f i f min f max f min even after transformation our dataset is still sparsezeros are unchanged by the transformation yet features with greater variance such as visibility or likes have less spread between the iqr and outliers the median value of all reactions is zero and nonzero values in those features are all in the fourth quartile likes have the largest interquartile range though the median is still close to zero page visibility and likes have the highest median values of all features supervisedlearning models to explore the relationships in our dataset further we isolated two feature subsets and trained two supervised learning classification algorithms with them we used decision tree and random forest algorithms because of the insight they provide into the relationships between features and our feature sets are detailed in table 1 we were interested in gaining insight into the extent to which users interactions could be related to articles subject matter and so we selected article subjects as the class labels for our models this gave us four targets for our multiclass classification models to predict with the first set we were interested in finding the extent to which clickbased reactions that are immediately available to table 1 displays the accuracy and area under the curve of our models and figure 4 shows the results of our models using several different metrics for reference scores are shown against the baseline which represents random guesses at which of the four class labels an article belongs to feature set b produced significantly better results than a with both algorithms average accuracy of models with feature set b is 160 greater than the baseline while feature set a is only 58 greater figure 5 shows the relative importance of each feature in our models in feature set a likes have the greatest weight accounting for 51 of the result on average between the two algorithms the weight of reshares is the second highest importance accounting for an average of 27 of the result in feature set b visibility is the most important feature accounting for an average of 94 of the result the remainder of the weight is spread relatively evenly among the remaining features discussion and conclusion our new dataset of clickbased reactions to scholarly content on facebook offers a wealth of possibilities for researchers interested in social media analytics we have demonstrated how it can be used in the exploration of user interactions with scholarly content on facebook and how clickbased reactions are an effective data source for investigating indicators of user emotional attitudes results from the models trained and tested on our dataset suggest that the number of followers a page has may be predictive of article subject matter this indicates that there may be patterns in the content shared on facebook pages and the number of followers these pages have it may prove useful for researchers to explore the ways in which facebook page popularity is stratified by the type of content displayed on their pages we have also suggested some interpretation of facebook clickbased reactions that are not immediately apparent notably that reshares convey an emotionally positive feelings toward content and that sad and angry reactions express similar affects these relationships are not at all obvious and give us insight into how these features are being used in practice

research on socialmedia platforms has tended to rely on textual analysis to perform research tasks while textbased approaches have significantly increased our understanding of online behavior and social dynamics they overlook features on these platforms that have grown in prominence in the past few years clickbased responses to content in this paper we present a new dataset of facebook reactions to scholarly content we give an overview of its structure analyze some of the statistical trends in the data and use it to train and test two supervised learning algorithms our preliminary tests suggest the presence of stratification in the number of users following pages divisions that seem to fall in line with distinctions in the subject matter of those pages

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huge array of military equipment and security services teargas canisters are arranged in glass cabinets missiles glint under spotlights guns are lined up to try out against painted targets tank barrels are raised there are also body parts not the casualties of war they are nowhere to be seen but displays of gloves boots and gasmasks here military equipment steps forth as a commodity it is changed into something transcendent 1 a bomb becomes an object of exchange a focus for fantasies and profit deals are facilitated with lavish hospitality hostesses weave through the traders politicians and clients offering pretzels wine and lipstick smiles a string quartet plays mozart from the back of a military truck alliances are formed with a handshake backslap and glass of champagne the polite rituals hide a corrupt trade arms are sold to repressive regimes authoritarian states and countries engaged in aggressive wars these deals are not illicit but actively promoted by western governments the uk has sanctioned £28 billion worth of arms sales to saudi arabia since it started to bomb yemen in march 2015 including bombs air to air missiles components for bombs combat aircraft and military support vehicles 2 in the five years following the violent suppression of prodemocracy protests in bahrain in 2011 the uk government facilitated £45 million of arms deals to the country including machine guns grenades and assault rifles 3 during this period prince andrew entertained the king of bahrain at the royal windsor horse show and the prime minister welcomed him to 1 karl marx capital volume 1 1867 spring0708marxcommodityfetishismpdf 2 stop arming saudi arabia legal action launched caat news 240 apriljune 2016 89 saudi attacks have hit refugee camps schools hospitals a wedding and aid facilities amnesty international claims it has evidence of a british made bomb used to destroy a civilian building more than 5800 people have been killed tens of thousands injured and 28 million displaced yet when the eu parliament voted for an arms embargo on saudi arabia david cameron reassured the arms company bae systems that he would continue to help it sell brilliant things to the country downing street 4 the arms industry is given an appearance of civility through the hierarchical rituals of the establishment arms fairs are an extension of this how to strip away the polite veneer the dada poet hugo ball wrote all satire and irony lead back to naivety5 she started visiting arms fairs as an official war artist there was nothing official about her statusthe title was selfappointed that this was sufficient to bypass apparently stringent security checks indicates that the idea of the artist has a cultural kudos that is particularly useful to institutions the uk arms fair dsei even offered to exhibit her work on the strength of the application the offer was withdrawn as soon as they saw the drawingsindeed she was asked to leave following this she gained access as a researcher by submitting a sham abstract to a conference that was taking place within the fair as part of a growing association between arms manufacturers and universities the invitation was cancelled when she submitted the full paper she now gets in as the managing director of a fictitious arms company by wearing a suit and paste pearls art and university research like a pinstriped suit are often part of a veneer of civilization that normalizes war as walter benjamin observed there is no document of civilization which is not at the same time a document of barbarism6 we begin by looking at the ways art and ir collude in the business of war then we use the drawings as a starting point to imagine a critical collaboration between art activism and ir what is the point of art what does it matter if you spend your time goldplating the heels of boots or carving madonnas… people are being shot there is mass profiteering and hunger people are being lied to what is the point of art 7 art has an ambiguous role in capitalism separated from mainstream production by historical circumstances it has an ethereal aura that at times provides a cloak for corruption the dada artist george grosz described this when he railed against the cloudcuckooland tendencies of socalled sacred art… while military leaders painted in blood 8 yet art also offers methods that are particularly suited to conveying the brutal excesses of capitalism to understand this contradictory potential it is necessary to look back at the historical disconnection of art from society the modern western idea of art emerged in the c18th and c19th as a defensive reaction to the emphasis on reason in the enlightenment and mass production in the industrial revolution 9 the word aesthetic was coined in tandem borrowed from the greek to describe aspects of sensuous experience and expression overlooked by rational enquiry 10 as part of the division of labour in the c19th art was defined as a realm of specialized aesthetic production as a result art has come to represent a zone of sensuous experimentation and play apparently unfettered by the demands of industrial and academic production the freedom is relative although art appears to be separate from capitalism it is inevitably entangled within it as julian stallabrass points out highend art offers a speculative market that mirrors the financial markets while giving capitalism a bohemian gloss 11 even so it is undeniable that the historical separation of art from industrial production has given artists an unusual degree of freedom and this holds out the possibility that artistic practice might be put to radical use the playwright bertolt brecht argued that art has the potential to reveal the inner workings of capitalism discovering the causal complexes of societyunmasking the prevailing view of things of those in power12 and indeed there is a reason that art might be 7 george grosz george grosz in dawn ades ed the dada reader a critical anthology 310 particularly well suited to this taskcapitalism also uses aesthetic methods art may have become known as the realm of the aesthetic but aesthetic expression is not limited to art eagleton uses the term to describe the breadth of visceral experience and expression that lies outside the rational the aesthetic concerns this most gross and palpable dimension of the human which postcartesian philosophy in some curious lapse of attention has somehow managed to overlook 13 it is any form of experience that touches the gaze and the guts and all that arises from our most banal biological insertion in the world 14 as such the aesthetic is dialectical at once radical and reactionary it describes both the ornaments of civilization and the animal drives that subvert them it conveys bonds of feeling that unite and divide many aspects of contemporary international relations seem to defy rational explanationwars against terror defensive arsenals that can destroy the planet arms sales to repressive regimes as anne orford argues in the seventeenth century and again today reason cannot fully explain the violence unleashed by the stateor the international communityin the name of protection15 president eisenhower warned of the unwarranted influence of the militaryindustrial complex and the potential for the disastrous rise of misplaced power 16 how to study this what does influence look feel and smell like as eagleton puts it how can reason that most immaterial of faculties grasp the grossly sensuous 17 here art can perhaps contribute but there is a catch art is particularly vulnerable to appropriation artworks may be able to glukacs aesthetics and politics 82 13 eagleton 1990 13 14 ibid convey the grossly sensuous guises and effects of power however such insights are drained of meaning if they are presented through the usual art world channels as valuable artifacts benjamin warned of photographs that make human misery an object of consumption 18 as eagleton says how idealist to imagine that art all by itself could resist incorporation 19 benjamin argues that politically effective art is not just a matter of form or content it is necessary also to change the means of production and dissemination 20 the task is to turn readers and spectators into collaborators 21 an alliance between ir art and activism might be a start art and ir for most of irs history readers and spectators have indeed been collaborators they have collaborated in shaping a discipline that celebrates abstract theory focuses more on the causes of wars than on the cannon fodder fighting and caught in wars injurious content and in us ir hypothesis testing using largen data sets is continually fashionable nordic countries have produced a sustained peace studies subfield and journals to match from the journal of peace research to security dialogue however the first one also showcases quantitative studies and both go along with the larger tendency in global ir to elevate abstract reasoning above the art and tears of war the gritty politics of wars and peace are appropriated absented or drained of meaning in a good portion of the fields output in addition the cold war ushered in strict border controls that delineated true ir from other fields all the arts where voices dramas stories and textures of conflict and dailiness have been readily available were seen as far outside ir they could be smuggled in only when studying regimes that consciously built aesthetics into their marketing efforts eg nazi gigantism in architecture and academic blandness in paintings soviet socialist realism and the weapons parades once organized by both regimes and continued today by north korea 18 walter benjamin the author as producer in charles harrison and paul wood art in theory 1900 1990 an anthology of changing ideas 487 19 eagleton 1990 372 20 benjamin 1992 486 21 ibid 488 there was so little openness in ir until fairly recently that one could apply the term censorship to describe refusals to countenance anything wandering in from outside established disciplinary borders 22 censorship is of course a political act one that artists are familiar with from the many occasions when artworks are declared offensive blasphemous heretical dangerous naked and wrong in image and words the nazi degenerate art exhibits of 1939 showed modernist artworks stolen from german museums and jewish collectors as the ugly morally corrupt and despicable artifacts of social groups requiring elimination segue to the cold war 1950s and us congressional insistence on vetting american modernists before their works could be exhibited abroad with the museum of modern art in new york allegedly pushing back by promoting the abstract expressionist works painted by vetoed artists congress also tried to censor the national endowment for the arts in the late 1980s and 1990s on the grounds that it was funding controversial art exhibitions that assaulted american symbols as well as its heteronormative norms and then there was the enola gay case that resulted in the cancellation of a planned exhibition at the smithsonian for the 50 th anniversary of the end of world war ii it was to have shown one of the planes that had transported atom bombs to japanese targets in 1945 but military leaders congressional members and veterans balked at curator plans to indicate the extent of japanese killed by those bombs some might also remember the fate of the international freedom center originally planned for the world trade center rebuild survivor censorship prevailed when a group called take back the memorial began warning new york that it was about to get a leftintellectual blameamerica museum of september 11…nearly overnight the centers chief political backers including hillary clinton withdrew support and the project abruptly ended 23 in each case critical aesthetics met silencing censors applying a politics of disapproval the sketchbooks have also survived a politics of disapproval centering both on the audacity of sketching within arms trade fairs and the images produced which are not sympathetic to the event or the participants that ir researchers are able to view these artist sketchbooks here exemplifies an artistic evasion of corporatestate censorship as noted it is not easy to get into such fairs or to be a masked interloper within the cultivated ambiance surrounding killer arms the ir researcher can only imagine the anxiety that accompanies the renegade act of drawing instances of that mass profiteering grosz condemns amid the champagne fruit delicate chocolates and missiles and the quartet playing mozart an aesthetic flirtation with the oldschool sense that where there is recognized art there is refinement no violence here no people being shot mozart off the back of a military truck in an arms fair code that dada and code it international relations a short collaborative dialogue to begin sylvester in method meets art patricia leavy argues for thinking both like a researcher and an artist in order to create socially useful work24 scope those sketches the researcherartist is at the far right end of the first full sequence visible in the image she is ostensibly studying the catalogue of arms the way academics might study the arms industry only she is likely a potential buyer rather than a critical theorist she looks comfortable focused at ease with the material she is reviewing she could be someone i might know in ir she could also be a spy an outlaw in the arms fair someone who is studying that catalogue with critical censorious purpose gibbon if we accept eagletons definition of the aesthetic as aspects of human experience that lie outside reason as that which is bound up with our creaturely life 25 then the term encompasses contradictory aspects of an arms fair beneath the polite façade are conflicting disruptive drives and emotions i am aware of this in myself i may be wearing a suit but i know i am a fake the first day of an arms fair is the worst i am gripped by fear twisting guts tense shoulders creeping skin drawing while nauseous i realize i am not alone there is often a disjuncture between the respectable dress of my subjects and the uneasy figures within john berger describes drawing as an act of discovery bringing to attention detail that might otherwise be overlooked it is the actual act of drawing that forces the artist to look at the object in front of him26 while drawing i notice a sweaty lip hunched shoulder a contorted brow expressions of lust anger and greed break through the façade it is not just me who is acting a part sylvester because of the contradictions these sketches reveal we might consider the drawings as a set of research notes on arms fairs picasso would likely have gone along with that idea he said i never made a painting as a work of art its all research27 pictured in the sketches are many men none fitting the image of the masculine warrior the shoulders are indeed rounded fatigue is evident in those bodies as are the too many glasses of bubbly consumed over the course of a day most of the men just stand around not a single sale seems to be taking place is that the case are the fairs mostly about looking and hobnobbing with actual sales deals taking place in some back lot what does the arms sale look like exactly how is the money transferred that the sketches picture arms fairs without evidence of arms deals raise questions about how to see look into conceptualize arms deals from arms fairs even when they are smiling the men do not look like happy fellows who have sealed any deal and with the one exception of the woman perusing the weknownotwhat reading material in a concentrated and interested way no other woman looks absorbed in anything having to do with actually selling and buying arms theyre arranging their bodies and draped attire showing off legs in pointy shoes with heaven heels they look everlastingly bored like slumping stage props gibbon an arms fair is ostensibly an exhibition 28 no money changes hands as if this would lower the tone deals take place later after the hospitalities the business of arms trading is an example of what jonathan harris calls a dramatized public life performance 29 the acting out of public professional roles harris describes a miserable gap between the expectations of how these performances should look and the way that individual bodies perform usurped by conflicting emotions and drives 30 drawing is never objectivethere is always a choice of what to include and what to leave out i focus on the miserable gap in arms traders performances that disrupt the civility of the show a lecherous leer an overly enthusiastic turn with a gun the continual desperate drinking only one group maintains the mask of respectability the mannequins that are scattered across the hall displaying private security kit the plastic flesh is unblemished by rich food the classical features show no emotion they contrast cruelly with the traders who surround them drawing offers a method to convey the contradictory aesthetics of an arms fair the formality of the exhibition and the stirrings of creaturely life 31 that disrupt it sylvester the weapons that are set about also look bored inert but potentially not inert at all they are ponderous pokeups here and there something for the men to lean against and the women to play to the anthropologist veena das is convinced that social researchers should descend into the ordinary more than we do where much of life is experienced and recovered while researchers are looking higher up for significance 32 a sense haunts these sketches that desultory arms fairs are part of the ordinariness that creeps over war war veterans describe it as a lot of standing around a lot of waiting my days passed sitting in the dust throwing rocks into a bucket missing didnt matter 33 of course there are hellbreaking moments of war too but lets not go there this is a refined arms fair after all the sketches communicate the interregnums of war moments when security sentries face nothing more threatening than an artist a researcher with sketchbooks gibbon these concertina sketchbooks appeared in shock and awe a group exhibition of war art at the royal west academy in bristol uk 2014 there was space in that gallery to show the complete sketchbooks with misdrawn lines smudges and interruptions that conveys something of the experience of being inside a fair and perhaps makes it possible to imagine trespassing its boundaries the rwa is unusual in encouraging political dialogue through the text that accompanied the drawings and through artists talks during the exhibition still in my world of art the emphasis on individual artists means that political concerns can all too easily be interpreted as an individual quirk sylvester early feminist ir concerns were similarly deemed quirks of some women scholars an artistresearcher traveling incognito can evade the censors and pursue an ethics of care ethics of protest or right to information unfettered the brilliance of the guerrilla girls feminist group lies partly in the costuming gorilla masks hide identities and enable clever picture messages about womens mistreatment by arts institutions to be heard seen and appreciated assuming a false identity though is something university ethics boards might not tip as a legitimate research tool if proposed by social science researcherartists if the researcher is an artist romantic ideas of artistic genius pegged to academic border politics lets her off the hook the fake pearls do too if the venue is an arms fair security such are the vagaries of the large censorship industry gibbon sara bevan curator at the imperial war museum suggests that contemporary forms of violence demand new approaches to the curation of war art 34 janna graham at the nottingham contemporary gallery argues that if creativity is to be harnessed as a critical tool there must be nonhierarchical collaborations between artists curators educators and activists 35 sylvesters experiencing war was an example of this kind of collaboration where 34 sarah bevan art from contemporary conflict 35 janna graham spanners in the spectacle radical research at the frontlines fuse magazine people from a range of backgrounds presented diverse experiences of war 36 in the future such events could be held in galleries museums and contested public spaces sylvester indeed and invite the woman in the sketchbook who is reading in an arms fair no matter her motives at that moment she is defying all efforts to get her into the weapons game and out of a book gibbon yes but here comes that security guard its you again you and your drawings have been linked to protest get out it is the guards task to keep art research and protest separated the challenge is to bring them together april 1 2010 36 christine sylvester ed experiencing war

in method meets art 2015 patricia leavy argues for thinking like both a researcher and an artist in order to create socially useful works christine sylvester teams up with visual artist jill gibbon to think through her drawings about practices that can radicalize artwar consciousness and motivate action both authors bear in mind words george grosz screamed nearly100 years ago what does it matter if you spend your time goldplating the heels of boots or carving madonnas people are being shot… the essay unfolds from a brief remembrance of debates about art and function and considers what it is to think like an artistresearcher or not as is often the case in ir war studies and art making on issues of war the coauthors present viewpoints on the drawing and end by working together toward a researcherartist mode of being doing and thinking about war through art

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introduction s ustained engagement with health care and long term adherence to a medication regimen is essential to reducing the morbidity and mortality of people living with hiv and yet in the united states the 2011 care cascade a visual model used to identify gaps in services for people living with hiv across the continuum of care illustrates a powerful reality that the majority of those diagnosed with hiv are not receiving sufficient health care 1 recent research demonstrates that optimal health outcomes for hivinfected individuals require care milestones to be met including linkage retention medication adherence and viral suppression between these milestones are gaps that limit linkage to and retention in care these gaps have been attributed to financial barriers organizational barriers distrust of the medical establishment 23 ongoing substance use mental illness and homelessness 4 5 6 7 for people living with hiv and cycling through the criminal justice system engagement in care and adherence to a treatment regimen are further complicated 8 estimates are that 1 in 7 people living with hiv will pass through a correctional facility 9 jail facilities are used to confine accused persons awaiting trial and are also used to incarcerate persons for up to 2 years usually for minor offenses about 17 81011 of the 86 million people passing through jails in particular are infected with hiv of these 55 reported a recent substanceuse disorder and 64 reported having a mental illness diagnosis 12 treatment of these typically debilitating issues in a jail setting is challenging due to the time interval of detainment otherwise known as a short stay an average short stay is up to 2 weeks 13 initiation or reinitiation of antiretroviral therapy department of medicine 1 center for aids prevention studies and 3 positive health program university of california san francisco california 2 san francisco department of public health san francisco california may occur as a result of being detained in jail pant pai and colleagues 14 reported on treatment patterns among a sample of 512 hivinfected inmates who had a history of multiple incarcerations within the san francisco county jail system over a 9year period they found 15 of inmates were in a continuous pattern 14 these results support those of other studies illustrating that it is highly unlikely that men and women in jail will continue to take art once they are released into the community 1516 nevertheless the results from the pant pai article are encouraging because they demonstrate that it is possible to sustain a treatment regimen within a context of multiple incarcerations patient navigation may be an effective model of hiv care coordination 17 that can facilitate greater continuity in care and treatment particularly for men and women released from the criminal justice system to date there is no standard definition of patient navigation instead the duties and diversity associated with navigator programs appear to reflect the availability of resources to fund such a program and the associated illness of interest clinicbased navigators are likely to have access to patients health status and medical information they are also likely to interact with the medical care team and may work on issues related to navigating treatment options treatment adherence and specialty care appointments these navigators may be trained as nurses or social workers and are expected to provide a level of support that is commensurate with their educational background whereas communitybased navigators are likely to have responsibilities related to navigating a wide variety of services in addition to medical care for example communitybased navigators may accompany patients to medical visits but have no interaction with the medical team they are unlikely to have access to the patients medical information andor they may not be responsible for supporting treatment adherence finally peer patient navigators located in either a clinic or communitybased setting are members of the community they are serving and have explicitly been hired because of these overlapping experiences not necessarily because they are trained to support care engagement patient navigation in the world of hiv is relatively novel and currently understudied in 2007 bradford published the first article reporting on the use of patient navigators in the field of hiv care 18 the professional duties of a navigator are not well specified yet the use of navigators in hiv care settings is on the rise navigator programs emerging in the recent care cascade climate are most often designed to facilitate patient retention in care and to link outofcare patients with services however the efficacy of such interventions remains largely unknown while there is evidence linking patient navigation to a reduction in health disparities in the field of cancer research 19 20 21 little is known about the mechanisms by which the model works to achieve these changes to explore these mechanisms we undertook an ethnographic study to explore the complex strategies roles and responsibilities of the patient navigator in aiding the establishment of longterm engagement with social services and health care jail detainees are targeted with services such as release plans but little research has systematically observed how recently released detainees make their way back into community services including medical care while being aided by a navigator methods intervention study and setting this article describes the findings of a qualitative research supplement to a larger projecta 5year randomized controlled trial that tested the effectiveness of a patient navigatorenhanced case management intervention for hivinfected individuals leaving the san francisco county jail system a locally established communitybased organizationthe san francisco pretrial diversion projectprovided the intervention which included injail hivprevention counseling and 1 year of postrelease intensive case management enhanced with patient navigation the standardofcare comparison group received asneeded postrelease case management provided by the forensic aids project a program of the san francisco department of public health the goals of the intervention included reducing sexand drugrelated hiv transmission risk increasing hiv medication adherence reducing hazardous drug and alcohol use and reducing reincarceration accordingly case managers attempted to connect participants with appropriate community services to increase the likelihood that they would be stabilized in the long term patient navigators worked closely with clients in the field to ensure successful engagement with services and continuity of care case managers conducted psychosocial assessments and provided prevention education in addition they developed with client input a dischargeongoingcare plan navigators assisted in the implementation of the dischargecare plan by escorting clients to appointments and they provided coaching on how to connect and interact with programs in the system table 1 outlines the tasks undertaken by case managers and navigators hiring patientnavigators colleagues working in the criminal justice system referred the intervention provider to patientnavigator candidates navigators were hired because they were peers of their future clients they also had a history of consistent engagement with social services and medical care and possessed good organizational and communications skills all navigators had been abstinent from drugs and alcohol and had not been in jail for 1 year before being hired many of the patientnavigators had not previously held jobs or had been out of the work force for many years navigators attended trainings on a number of relevant topics such as professional behavior confidentiality time management and communication skills in addition they received ongoing support to apply what they learned in trainings as well as clinical supervision although the original design of the study was to create enduring navigatorpatient dyads this was ultimately not possible because of limits on the income navigators could earn to remain qualified for socialwelfare benefits thus navigators were not assigned to one particular client with whom they might work closely over a long time instead navigators assisted any client needing services during a given workday each navigator worked 1012 h per week usually across two workdays on each workday at least two navigators were on duty navigators were hired specifically because they had criminal histories so they were unable to obtain the security clearances necessary to provide services inside a jail for this reason case managers provided all injail services including postrelease planning and hivrelated counseling and they made referrals to community services once a client was released the case manager worked with patientnavigators to monitor adherence to care plans and provide clinical supervision all patientnavigators involved in the intervention were enrolled in this ethnographic study ethnography overview we used ethnographic research methods over a 10month study period to understand how the patientnavigator model worked in everyday practice through firsthand unobtrusive observation and insight the study ethnographer was able to characterize the processes by which an intervention was delivered these observations were complemented with indepth openended interviews of both clients and navigators study procedures were reviewed and approved by the committee for human research at university of california san francisco field observations an ethnographer conducted a total of 29 field observations of 15 unique clients over 10 months the ethnographerhired because of his familiarity with local social services as well as jailtocommunity transition issues and trained in ethnographic methodsconducted direct observations and accompanied patientnavigators and their clients to service appointments the ethnographer spent approximately 75 h in the field and produced detailed observational field notes indepth interviews we conducted baseline and followup indepth interviews with all of the patientnavigators and indepth openended interviews of clients many of the clients interviewed were also study participants during the ethnographic field observations so we had multiple data points with which to contextualize and triangulate data after an initial comparison of the field notes and client interviews we conducted followup interviews with navigators to verify and enhance our understanding of findings that emerged in this preliminary analysis we developed interview guides for patientnavigators and clients after analyzing a subset of the field notes from the first five ethnographic observations interview topics included life histories of incarceration drug use sexual behavior and hiv care and details regarding the navigatorpatient relationship and its potential impact on engagement with services for instance we asked a version of these questions to both navigators and clients i want to ask about some of the successes and failures in your work can you think of one of your best clients and tell me about your interaction what makes it click for you and that client how do you know if youre successful or not followup interviews with patientnavigators focused on emerging themes from the baseline interviews and field notes navigators and clients were paid 40 for participating in the indepth interviews all interviews were audiorecorded and transcribed all patientnavigators were eligible to participate clients were eligible if they had two or more service contacts with a patient navigator and if they were enrolled during study assessments conducted 2 6 and 12 months after release from jail clients were selected by convenience sample if they met the study criteria they were approached and asked to participate data analysis ethnographic research allowed us to use inductive methodology to understand how patient navigation works rather than test a hypothesis accordingly our analytic approach was based in grounded theory which seeks to develop knowledge based on information and insights provided by the people who experience a particular phenomenon 22 we used contextualizing and categorizing strategies to analyze the data 2223 each transcript was assigned a primary analyst in charge of systematically reviewing the interview and drafting a contextualized interview summary following this step the primary analyst categorized or applied coding categories to segmented text within the interview a secondary analyst reviewed the contextualizing summary and verified the coded interview twenty codes eventually emerged for the navigator data set and 24 for the client data set for this analysis we closely read all text associated with the following codes peer connection navigator as role model service engagement navigator strategies and service history we read these excerpts to understand the strategies roles and responsibilities of patientnavigators as they worked with clients to improve engagement with services results we have organized our findings into two sections in the first we provide an indepth portrait of the typical daytoday activities of navigators as they worked with clients we present data from the ethnographic field notes to best exemplify the interactions between the navigators and clients this section provides a detailed description to set the stage for the presentation of our main finding building peer connections with clients was crucial to facilitating their engagement with the services system navigators and clients both reported that this connection was integral to active and effective participation in various social and medical services we argue that these connections were initially fortified by social concordance and then deepened as the navigator and client shared experiences of accessing complex unfriendly systems that are replete with requirements and conditions that even the most resilient and resourceful of persons would feel challenged by we enrolled 31 clients and 5 navigators in our study some clients and 1 navigator did not provide information on incidents of incarceration the demographics of the participants enrolled in the qualitative group were similar to those of the overall study population with the exception of slightly higher percentages of africanamericans and latinos enrolled in the ethnographic study each participant that is quoted multiple times has been assigned a pseudonym all other quotes represent unique participants daytoday tasks of patientnavigators one of the main responsibilities of patientnavigators was to escort postrelease clients to medical court and socialwelfare benefits appointments successfully engaging with community services after release from jail was challenging for clients to manage on their own particularly if they did not have a social network to rely on for physical logistical financial and psychological support a client said every time you go to jailit puts you behind on a lot of shit doctors appointments money that you are supposed to receive everything stops for you when you go to jail and when you come out all of a sudden youre behind one of the goals of navigation was to rebuild these socialservices relationships in order to facilitate getting aheador more accurately catching up for a typical patient appointment the supervising case manager would assign a navigator the assigned navigator would receive relevant clinical and social services information about the client along with a specific navigationrelated task that was to be performed immediately before contact with the client because the pools of navigators and clients were relatively small navigators did develop relationships with some clients particularly those with acute or multipleservice needs however the design of the intervention was such that navigators were likely to meet a new client with each assignment accordingly the navigator would meet the client at either the clients residence or the intervention site which also served as a dropin center and would accompany the client to the referral site in most cases this involved taking a city bus or walking to the appointment there were also instances when a client chose to meet a navigator at the appointment site rather than be escorted there the availability of an escort proved to be essential in getting most patients to attend and complete their appointments for example the ethnographer noted that navigators helped clients cope with the physical effects of prescribed methadone andor illicit drugs making sure that clients got on and off a bus at the appropriate stop or remained alert enough to complete an appointment a navigator named hector accompanied a female client to a medical appointment at a hospital the following excerpt from the ethnographers field notes describes the appointment the study participant arrived a little after 12 pm the participant is female africanamerican and appeared to be in her mid40s she was neatly dressed in a black leather jacket over a blackandwhite animal print shirt blue jeans and white shoes the first impression of her that popped into my head was that she might have been a former substance user her mannerisms reminded me of many substance users i had met and worked with in the past i also noticed that her hands were a little swollen and had a slight reddish color to them i have seen this many times with active substance users although she didnt openly talk about any past substance usage she did mention to one of the navigators about having received a dose of methadone prior to arriving at the dropin center because her appointment wasnt until 145 hector brought a plate of food from upstairs and she began to eat making the clients comfortable and welcome seems to be extremely important to the staff this is only my second visit as a tagalong and on both visits the staff was extremely attentive to the needs of the clients they always asked if the client was hungry or thirsty and made them feel comfortable before they conducted any business with them after the client finished eating we headed out the door for the trip to the local hospital during the walk the three of us she seemed to relax and be more comfortable with me tagging along after thatat mission street we caught the 14 bus the bus was full with just a few seats unoccupied the participant was able to find a seat while hector and i stood in the aislei noticed that the participant started nodding off soon after we were under way i assumed that her dose of methadone was starting to kick in hector roused the client when we arrived at the hospital i have no doubt in my mind that she would have slept through her stop and might have been late or missed her appointment entirely had he not been with her we arrived at the hospital about 125 pm and proceeded up to ward x the participant checked in at the reception desk and received a number we sat and waited for her name to be called the waiting area was fairly full and busyher name was finally called about 2 pm she left the reception area and followed a staff person into the ward she returned to the waiting area about 5 minutes later she apparently just had her vital signs taken and was told to return to the reception area and wait for her doctor to call her she opened a book and started to read i noticed the title of the book was staying soberguide to relapse prevention she had the book open on her lap but started nodding off again so i dont think she actually read much of it while we waited at one point she vented a little frustration about having to wait so long and hector provided a sympathetic ear i felt having hector present helped keep the client from getting too frustrated and possibly leaving the ward without seeing her doctor at about 220 she was finally called back to see her doctor her appointment concluded about 305 pm we left the hospital and rode the bus downtown hector thanked the client for successfully getting through the appointment and got off the bus there was some but not a lot of interaction between the navigator and the client my sense is that they were familiar with each other but werent particularly close there was some conversation between the two after the clients arrival to the agency but not much at one point the client and hector stepped outside for a smokethis was the second time i accompanied hector once again i was extremely impressed with his dedication and attentiveness he was readily available and stayed with the participant throughout the appointment while the participant was seeing her doctor he told me that he felt the appointment was going well mainly due to the disposition of the participant he said that some of his participants would become far too frustrated with the waiting and he would have difficulty getting them to stay this excerpt highlights some of the challenges that navigators faced in escorting patients to appointments the excerpt also details key strategies for managing these potential difficulties hector fed the client making sure she was physically cared for another navigator explained the strategy as first you eat and then well talk we talk better on a full stomach hector was also able to rouse the client at key points in the engagement process as the ethnographer noted she might not have made it to the appointment without his help last the navigator may have mitigated the patients frustration with the long wait times by attending the visit and enduring it with her thereby ensuring that the appointment was completed in our field observations we learned that the principal function of a navigator was to focus on problems both real and potential not only did they assist with the basic task of getting to and completing an appointment they also helped with special circumstances for example a navigator escorted a client to a court appointment and filled out a required form because the client had poor eyesight and was unable to do it himself in another example a navigator watched over a patients companion dog outside the social security administration building otherwise the appointment would have been missed because the dog was not allowed inside in yet another example a navigator escorted a male client from a residential drugtreatment facility to his home which he had not been to in months in order to retrieve a few personal items they arrived to find that the patients roommate had been lying dead in the home for 2 months the navigator took control by calling the police and dealing with the medical examiner the patient noted that the navigator didnt go crazy he kept it together and helped me keep it together you know and we did what we needed to do the aforementioned navigators helped with basic tasks as well as with idiosyncratic events meeting these needs is a fundamental requirement for transitioning clients back into the community consider the case of barry a male client who enrolled in the study after his first jail detainment at age 52 he had moved with his partner to the san francisco bay area about 10 years earlier two years after their arrival they ended their relationship and barry started selling methamphetamines and increasing his use of the drug in 2010 he was arrested and served 4 months in county jail at the time of his involvement with this project he was homeless had recently been hospitalized twice for cellulitis in both legs and was suffering from severe depression additionally he was not on antiretroviral medications and had begun using methamphetamines again barry felt that he had gone from being a professional to being pretty much on my own with almost nothing his income had been cut off when he was arrested so at the time of his participation in the project he faced not only a tough spot economically but also a need to put his life back together in the field observation of an appointment barry had at the social security administration the ethnographer noted that he broke down and cried during parts of his responses during the interview in a fragile state barry appreciated the support that his navigator and others offered him navigators know what you can often do and not do and the challenges that you face they understand how things that maybe seem to somebody else on a daily basis to be a breeze can become a very challenging thing to do i mean just for example when i applied for ga the fact that the navigator came in and walked me through that process made all the difference in the world you know i got through that whole process within a daythat and medical we got that all done in one day even less than a day basically and i dont think that i wouldve gotten that done within a week had i done it myself just because at that point in time i was really scared and nervous and unsure everything seemed to be a challenge another participant spoke of the discontinuities and disruptions that incarceration can cause pat a 34yearold male client had been incarcerated four times for drug offenses during the 3 years prior to his involvement in the study in an interview he said its really hard by yourself to start all over again when leaving jail despite the tumultuousness of his recent life pat reported that he had maintained an art regimen while living in the community and that at the time of his interview his viral load was undetectable he also reported using methamphetamines in a field observation the ethnographer accompanied pat and his navigator michael to a mandated court appearance the ethnographer entered the extremely crowded courtroom just as the navigator was emerging from the judges chambers according to his field notes michael motioned for me and pat to follow him out of the room once in the hallway he informed pat that there was a bench warrant out on him evidently he had failed to appear before the court the previous week and a warrant was issued for his arrest michael was able to speak with the judge in his chambers and get him to stay the warrant under the condition that pat would appear before the court on wednesday we walked out of the center and pat thanked michael for his assistance later in an indepth interview with project staff pat offered the following comments on that particular experience in court it feels like as much as you know everything dealing with the court thing is a new thing like its a new thing how to do them for example go to court and talk to the judge i have to make another court date because that date doesnt work its like for me i dont know how to do itthey kind of call there and tell them and they tell me like okay this is your court date that kind of thing like i didnt have any idea if i was by myself i think i would be going round and around navigators know and they put things together patientnavigators build connections and serve as role models patientnavigators reported that in order for them to work effectively and facilitate engagement with services it was essential to establish a trusting relationship with clients a navigator said if they feel a connectionthey will start opening up the building of rapport was achieved mainly by sharing experiences in client interactions navigators often referred to their own histories of drug alcohol use hiv and incarceration tim a 60yearold navigator who has been incarcerated over 80 times explained the experiences skills and assets that i have are that i have been in the life i know what it is to understand the shame and the guiltif we can share some of our personal experiences with clients it makes them feel more comfortable and trustingas navigators being hivpositive and in the lifestyle once they know that it tears down a lot of barriers its not just meeting someone that they know nothing about the implication is that interactions between hivinfected postrelease clients and nonpeer service providers can be challenging because the clients lack trust and both parties misunderstand each other it is tim said the similar life experiences of both navigator and clientand an ability on the part of the navigator to place these experiences at the center of their interactions with servicesthat can allow trust to be established and barriers overcome in addition to recognizing a similarity in life experiences patientnavigators reported that withholding judgment was also integral to building an effective relationship according to tim a person has to have compassion not to judge thats the first thing you cant judge a person because you got it and they havent got that or youre working towards to better yourself and theyre not hector the navigator introduced earlier confirmed tims point and said that a compassionate relationship can help disenfranchised clients engage more effectively with service providers i speak when its necessary i listen when its necessary i show compassion and i explain how to make it easier for us to get through a particular interview and clients feel comfortable with that and they feel confident knowing that im not going to belittle them or make them feel inadequate the importance of a peer connection was supported in the stories told by clients during interviews a female client said the navigator let me in on a little bit about her personal life and that means a lot because i feel like i have a closeness with her that i could tell her personal things about me another male client who had been incarcerated 7 times since 1982 reported feeling that he could really relate to his navigator because the navigator had been through it the client explained i dont know if i can listen to somebody that hasnt been through what im going through or isnt hivpositive you cant study doing drugs and you cant study going to jail thats something that you have to experience in order to be able to talk about it whenever i talk to the navigators anybody those are my first questionsare you positive yes have you been to jail yes have you done drugs before yes was it meth yes wow with the navigators im like damn i can really relate to you it really does matter and it was really surprising that navigator was like that because i havent been anywhere where its like that where i can relate to the person its just better that way because i cant listen to advice from somebody that isntthat really truly doesnt knowyou know youve been bad your whole life and you know everything that youve done has led up to this and you cant actually get advice from somebody that hasnt been through it this client cannot as he said listen to advice from someone who truly doesnt know other clients spoke similarly of the value that shared life experiences bring to their interaction with services a male client who had been incarcerated 3 times in the last 15 years said see l a case manager not affiliated with this project has never been on drugs or alcohol she doesnt know she knows from books its not the same you got to be in that for realyou got to be in this shit and go through ityou see it in the way they talk to you dont talk down dont try to make them feel small like its big you and little me just talk to somebody like its your friend for this client having life experiences similar to his providers was conducive to building a relationship grounded in equality and respect a relationship he desired and intimated was central to positive engagement with services for this client and others their relationship with a patient navigator was different and potentially more meaningful than previous patient navigation experiences with service providers who had not be en in that for real according to clients these connections are important because they help create a situation in which the client is more likely to listen to and act on the advice given shared experiences are a short cut to a client acting in accordance with what a navigator suggests or requires as one male client noted the life experiences of navigators can lead them to be very perceptive to your feelings and what youre going through barry introduced above expanded on the importance of this connection and described how it could impact a socialservices encounter the navigator is very grounded you know hes not like highfalutin or trying to be something that hes not i mean he is what he is and we often come down to the same kinds of conclusions i think about a lot of things and about different people and he has a sense like when people are too hard or too harsh on you or when people need to let up that has helped me barry pointed to how a client might come to understand that heshe shares a common set of values and assumptions with a navigator which can help facilitate successful participation in a services appointment for barry the navigator was almost an extension of himself an empowered surrogate by leveraging their life experiences navigators were able to develop trusting relationships with clients as their equals in doing so they created a bridge between clients and the services system along this line navigators reported another more complex task in their work it was necessary they felt to help clients reorient their relationships with the services system reducing their fear and apprehension and building more trust and openness as tim a navigator reported the fearsi can sense the ir fears with health care providers sometimes clients are not willing to expose or give any kind of information a male client further explained it is the way a service provider comes off as a person you dont make clients feel like theyre shit and you are better than them and you know whats best for them its the way you talk to people the way you treat them in trying to convey how navigators and clients were equals due to their similar life experiences a navigator tellingly reported that i was once using the system like theyre doing just to get another hit this indicates that disenfranchised postjail hivinfected individuals may be profoundly distrustful of and even antagonistic toward the system which includes healthcare services and socialwelfare programs for this reason if client relationships with service providers are founded on alienation then reorienting these relationships becomes necessary for the establishment of longterm care hector the navigator explained the major part of being a navigator is helping the next individual understand that these people in these agencies that we deal with and the resources that are out there are put in place to help us live our lives to the fullest if the objective is to create an understanding that the services system is in place to help clients live life to the fullest then navigators are struggling against the perception of many that the services system is something opposite that it is somehow oppressive or disengagingor even inhumane as one navigator termed it after helping a client through a 5hour appointment at the social security administration many clients came to regard their navigator as a role model a male client who had been incarcerated 7 times since 2000 reported with navigator s these people have been through what im going through the 3 navigators that ive gotten were hiv positive the 3 navigators ive gotten have been to jail the 3 navigators ive gottenthey all 3 have done drugs before so i can relate to them and i could actually look up to them and see that this is where being clean and being good can get me by identifying similar life experiences this client linked his own process of transformation to those of his navigators the navigators came to represent an end point or goal this profile of the navigatorasrolemodel was described simply by another male client who had been incarcerated more than 40 times since the early 1980s he a navigator with at least as many incarcerations did a drastic turnaround it shows that it can be done with adequate support men and women can move out of a jail setting and successfully reintegrate into healthy communities the peer navigators in this study for all intents and purposes worked as reintegration specialists their clients required substantial input on how to negotiate schedules to appear in court fill out bureaucratic forms and visit medical clinics navigators worked to get people to and from their important appointments this shepherding process created opportunities to demonstrate or model prosocial behaviors and it provided patients with support during a time of possible instability discussion through our ethnographic work we identified mechanisms by which the patientnavigator model works to improve health outcomes for a particularly vulnerable population of men and women living with hiv one of the reasons why the model seemed to function well for both clients and navigators was that their shared life experiences fostered easytobuild relationships and trust when this sense of shared experience was established clients were willing to accept the advice offered by their navigators as well as allow them to act in their interests this union of efforts helped alleviate the isolation and alienation often experienced by clients navigators were sensitive to what life was like for their clients because they themselves had walked the paths of incarceration and drug use and hiv infection with this insider knowledge they could anticipate clients needs in a way that other types of healthcare providers may not be able to another critical mechanism of patient navigation is that in this study the navigators worked well beyond clinic and servicesagency settings and had full license to spend time with clients in their worlds the patientnavigator model is intended to facilitate a clients ability to confidently and fluently navigate the care system achieving this goal requires an understanding of the barriers to and facilitators of system navigation for example one such barrier is transportation typically defined as either not having it or not having funds to pay for it the solution has previously been to provide a cab ride or bus tokens but in our study because of its ethnographic nature and close proximity to the everyday experiences of clients we found that even if they had access to transportation they often lacked confidence andor the knowledge of how to navigate it more specifically some clients lacked familiarity with the bus routes that led to healthcare or socialservices sites or they encountered minor mishaps that derailed the successful completion of their appointment having a navigator accompany a client from home to the location of a service can potentially foster greater independence on the part of the client on the other hand clients receiving methadone may not be in a position to fully operate independently if the dose compromises their ability to get from point a to point b as illustrated in the opening field note navigators in our study were often able to address client needs that might otherwise go unspoken or unmet in clinic settings for example peer navigators used a practical or intuitive strategy to engage with clients by first offering them food andor drink navigators anticipated that their clients struggled with food security and they wanted at minimum and whenever possible to meet this basic need the act of feeding clients and thereby giving them some level of physical comfort was not only a supportive gesture but also one that grounded peer and client in a common human activity eating together even if the peer navigator did not eat with the client the simple act of offering food is unique within the usual socialor medicalservice context indeed this offer appeared to be a mechanism that built rapport between navigator and client in addition to addressing a clients immediate needs of hunger or thirst another notable difference between the work of navigators and case managers was the amount of time navigators spent with clients as they attended appointments of all types the healthcare system in its current design rarely offers the opportunity for clinicians nurses case managers or health educators to provide services beyond the walls of the clinic navigators in contrast were not limited to serving clients in a specific setting in fact their role was to physically meet clients where they were at physical presence and accumulation of time spent together in combination with shared backgrounds of incarceration hiv infection and drug use may be the most important finding of our study patientnavigators who act as both a professional and as a peer may be uniquely able to address the challenges faced by postjail hivinfected individuals by modeling effective communications during interactions with providers in various service systems the navigators were also helping clients to intuitively build skills that could allow them to more successfully and independently navigate these systems indeed patientnavigators may provide the best model for improving access to care for a particular type of vulnerable population because the navigators themselves had previously been in that same category capitalizing on similarities or a shared identity is a topic of particular relevance in the study of health disparities research on the effects of racial and ethnic concordance discordance between patientphysician dyads is extensive and results indicate that racial concordance may be associated with patient satisfaction patients trust and adherence to medications 2425 however results from the cumulated research are mixed 2627 in 2008 street jr et al 28 published an article shedding light on the mechanisms through which concordance leads to improved patient outcomes they reported that the strength of patientphysician relationships occurred most often when patients perceived similarities in personal beliefs values and communication the study was designed to reach beyond demographic similarities to investigate the role of modifiable aspects of the patientphysician relationship we touch on this literature here because like the research on concordance we too capitalized on the use of socially concordant navigators the ethnic backgrounds of our navigators and their clients were diverse and no effort was made to match dyads according to race or ethnicity our findings support the positive effect of social concordance in our study concordance appeared to be the critical first step to establish trust between the client and navigator our study design had limitations our intention to consistently assign navigators to a personal caseload of clients did not work out as planned due to issues related to limits on the income navigators could earn to remain qualified for socialwelfare benefits we are therefore unable to report on the outcomes of more intensive stable dyads we did not compare our model of patientnavigation with other models such as one that employs patientnavigators who do not share any life experiences with the individuals they serve our conclusions are also limited to recently released jail detainees results may be different for hivinfected individuals who do not have jail experience even with these limitations though the data allowed us to identify important insights about the key mechanisms for a patientnavigation model that affects health outcomes for disenfranchised vulnerable hivinfected men and women exiting jail settings finally this was not an outcomes study we were not able to determine the effectiveness of navigation services we were however able to describe in rich detail how the model works for these highneed clients navigators in this study worked with clients who had severe social deficits it was through working with navigators that clients gained insights such as this is where being clean and being good can get me this study illustrates that navigators are well positioned to facilitate a successful transition to care and socialservices engagement among a vulnerable population we observed that the navigatorpatient interactions provided meaningful support and that this support was fostered in a context where the client and navigator shared a history of drug addiction criminal activity arrest and jail detention pairing a recently released client with someone from hisher community who has faced very similar life challenges is a compassionate response to the problem of recidivism this type of intervention which leverages the experiences of and skills developed by successful exoffenders has potential to break the cycle of reincarceration and suboptimal engagement with services we recommend further research into the training and hiring needs associated with this type of navigation program as well as future studies to determine whether this particular model of patient navigation can fill gaps across the continuum of care and thereby increase the number of clients who reach optimal engagement with medical and social services author disclosure statement no competing financial interests exist

hivinfected individuals leaving jails facilities typically used to confine accused persons awaiting trial or to incarcerate persons for minor offenses often face barriers to engagement with medical and socialsupport services patient navigation is a model that may ease these barriers by supporting individuals in negotiating fragmented and highly bureaucratic systems for services and care while there is evidence linking navigation to a reduction in health disparities little is known about the mechanisms by which the model works we present findings of an ethnographic study of interactions between navigators and their clients hivinfected men and women recently released from jails in san francisco california we conducted 29 field observations of navigators as they accompanied their clients to appointments and 40 indepth interviews with clients and navigators navigators worked on strengthening clients abilities to engage with socialservices and care systems building this strength required navigators to gain clients trust by leveraging their own similar life experiences or expressing social concordance after establishing meaningful connections navigators spent time with clients in their daytoday environments serving as mentors while escorting clients to and through their appointments intensive time spent together in combination with a shared background of incarceration hiv and drug use was a critical mechanism of this model this study illustrates that socially concordant navigators are well positioned to facilitate successful transition to care and socialservices engagement among a vulnerable population

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introduction in december 2019 pneumonia associated with the coronavirus disease 2019 appeared in wuhan china and caused mild to moderate illness for most infected people 1 in 2020 the researchers isolated a novel covid19 virus from infected patients 2 and the who formally recognized covid19 as a pandemic virus 3 the covid19 pandemic became a © 2023 the authors this work is licensed under the creative commons attribution 40 international license worldwide challenge affecting individuals of all socioeconomic groups races nations and continents 4 in jordan the who official records in november 6 th 2020 reported 101248 infected people and 1136 death cases this gives an average of 9926 cumulative cases per one million and around 111 cumulative deaths per one million indicating a high mortality rate since the beginning of the pandemic these numbers further showed community transmission of coronavirus among jordanian people however around 1786 infected cases needed treatment in hospitals that had exceeded the bed capacity of hospitals offering treatments for new patients this leads the government to lockdown schools universities mosques gems and cafes in jordan until january 8 th 2021 covid19 is a singlestranded rna and belongs to the coronaviridae family and beta coronavirus genus 5 covid19 has been reported as a communicable virus the pathogenicity of the virus has been linked to the envelope spike protein which promotes viral assembly and release 6 the symptoms of covid19 include fever dry cough fatigue pneumonia 7 difficulty in breathing chest pain difficulty in talking and moving lymphopenia gastrointestinal symptoms and asymptomatic infection 589 the elderly and patients with preexisting medical conditions including diabetes hypertension cancer heart lung liver and renal diseases have been noticed to have a higher potential risk for severe disease and mortality 7 8 9 10 sarscov2 can spread through body fluid droplets from the mouth or nose during coughs sneezes and talks 11 12 13 current treatment guidelines from center for disease control and prevention as well as who majorly focus on symptomatic management and application of infection prevention measures 14 15 16 17 18 furthermore there are global concerns about the attitudes and behaviors exhibited by the lay public toward people suspected or confirmed to have covid 19 this study aimed to investigate public awareness of participants regarding the current covid19 virus pandemic and the source of their information during lockdown which was considered very important for the protection treatment and management of covid19 infection methods study design and participants this study was conducted in jordan during the covid19 lockdown the study objectives were addressed in a descriptive crosssectional online survey eligible participants for the study were drawn randomly from the general public academic institutions and pharmacy students participation in the study posed no risk to the participants and was voluntary the study received institutional administrative approval and followed internal guidelines for human studies participants who completed the survey were considered to have given informed consent for participation in the study at the time of the survey due to the prevailing lockdown conditions to obtain a representative sample due consideration was given to the characteristics such as geographic region and type of work setup during data analysis additional factors such as age gender educational level and working experience were considered 13 sample size the minimum representative sample size of 385 was determined using the raosoft online sample size calculator 18 with a 5 margin of error a 99 confidence interval and a 50 response distribution based on this calculation 409 samples were used in this study survey development the questionnaire was administered in arabic several sources were used to generate a pool of questions considered to be relevant to the study objectives the questions were prepared and then reviewed by the research team in order to combine concepts and to remove duplicates if any the questionnaire of this study was based on a broad literature search using a variety of databases including research gate pubmed and google scholar thus relevant literature related to the public practice of participants was identified the questions included in the questionnaire were prepared based on reviewed literature with some modifications 20 the contents as well as face validity were carried out first a group of experts provided feedback on the items of the survey then it was modified as per their comments 21 next the modified draft of the survey went through pilot testing on 20 participants to provide feedback about the clarity and comprehensibility of the items in the survey the final version of the questionnaire comprised four main sections with a total number of 49 questions that addressed the aim of the study the questionnaire included the following aspects the first section included items to collect sociodemographic data such as sex age educational level occupation and healthrelated problems the second section included items aimed at assessing the knowledge and awareness of participants about covid19 the potential participants were asked how much they knew about covid19 including symptoms modes of transmission how to prevent transmission the spread of virus and awareness on source of information and the latest coronavirus updates regarding methods of treatment the third section asked about how much they knew about the effects of food and drugs on the immune system and protection against viral infections while the final section asked about the governments decisions activated from march 15 th 2020 regarding curfews and other decisions to protect the citizens in jordan and the role of jordanian health authorities in the management of covid19 pandemic and sufficiency of necessary awareness campaigns in the country 10 for each of these sections there were several detailed items eg participants were questioned about the modes of coronavirus transmission such as if the virus can be transmitted with respiratory droplets from person to person through close contacts and after touching surfaces that were contaminated by the virus other questions investigated participants awareness regarding highrisk patients in addition to the symptoms that are associated with coronaviruses such as fever dry cough and shortness of breath muscle aches and gastrointestinal symptoms also coronavirus treatment was questioned such as if the combination of hydroxychloroquine and azithromycin have been used as a preventive therapy against covid19 infection or if there is an agreement to use these antibiotics to treat covid19 infection 17 other questions asked about practices of participants to protect against coronavirus infection such as using salt gargles drinking of warm water taking immune boosting medications such as zn supplements vitamin c vitamin d and medicinal herbs such as the role of garlic ginger citrus fruits bananas almonds and walnuts were also questioned the questionnaire was formatted into google forms an internetbased software commonly used for data collection via a personalized survey 10 survey implementation study participants were recruited through social media those interested in participating can open a link to view the ethics committee approved information about the study initially and then proceed to the questionnaire to minimize missing data the participants were invited to fill all the items in the online questionnaire and at the end of the questionnaire participants were directed to click the submit option and finally the online questionnaire was sent to the drive afterwards the correct answers to the awareness part of the survey were provided to the participants to enhance their awareness about the prevention of coronavirus symptoms and suggested treatments statistical analysis data retrieved from the online survey were entered into microsoft excel and then imported into the statistical package for social sciences version 22 the descriptive analysis was undertaken using mean and standard deviations for continuous variables and then percentages for qualitative variables checking for data normality was carried out using the shapirowilk test with pvalue less than 005 indicating normally distributed continuous variables the differences between the various groups were evaluated using chisquare test and fisher exact test for categorical variables p005 was considered significant results knowledge attitude and practices during the covid19 pandemic were reported by 409 participants the questionnaire was collated and responses were analyzed to evaluate demographic data the sample size for the study was reached which exceeded the raosoft online sample with a mean age of 262 years the gender of the participants was 763 females while 689 of participants were not marriedsingle furthermore the majority of the married participants had at least three dependents or more 466 of the participants lived in amman the capital of jordan 455 of participants had a bachelors degree and 359 with a middle diploma degree at albalqa applied university concerning occupation 447 of participants were university students and 371 of participants worked in the government and private sectors furthermore majority of participants did not live with elderly people grandparents uncles or relatives regarding the sources of information about covid19 treatment the study indicated that most participants obtain their information mostly from the general social media followed by jordanian ministry of health official reports family and friends and published research papers and seminars regarding the perception believes attitudes and practices of participants during the covid19 pandemic about 839 of participants believed that covid19 appeared at the end of the year 2019 in the fish market and then spread to the rest of the world 472 were considered the bat the main source of the virus 814 thought the dry cough dry through and fever specific symptoms of covid19 infection 445 agreed the virus could stay on surface between 7 12 h while 372 of agreed that the immunocompromised patients were likely to die due to complication of covid19 infection the present study shows the extent to which jordanian society adheres to government decisions during a period of covid19 spreading for example 968 of participants abided by the curfew laws and also 949 accepted the government decision to impose home quarantine 978 of them were support decision to quarantine all arrivals to jordan through airports land and sea crossings furthermore 819 of people think that the government had succeeded in the current period in controlling the spread of this virus and has taken the right decisions with regard to the mode of transmission most of the participants agree that covid19 viruses can be transmitted from an infected person who does not show any symptoms and about 93 6 310 some data was missing subsequently totals do not always add to 409 car handles and door handles with alcohol before use it surprisingly about 707 of participants believed that wearing medical masks did not necessarily protect against coronavirus around 484 of participants believed that there are antibiotics approved for use in treating covid19 and 46 of participants supported the use of paracetamol only as an antipyretic to remove the symptoms of covid19 regarding attitudes and practices of participants about using medications in the prevention and treatment of covid19 193 of the participants agreed that there were antibiotics approved for use in the treatment of covid19 482 of the participants accepted the use of hydroxychloroquine and azithromycin for the treatment of coronavirus infection 226 of the participants were accepted using hydroxychloroquine only in the treatment of covid19 the most useful practice resulting in this study is the awareness of jordanian people of immunity and drugs that boost the immune system the data showed that 797 of people had taken immuneraising medications and vitamins to improve immunity and prevent infection by covid19 viruses interestingly the participant with a bachelors degree believe more than others in immunityboosting drugs and special vitamins in preventing the virus moreover 68 of them eat oranges citrus fruits and leafy vegetables to help to protect against coronavirus by improving the level of immunity for the reason that they contain high levels of vitamin c table 7 some data was missing subsequently totals do not always add to 409 discussion this study assessed participants knowledge practice and attitude among the jordanian population towards coronavirus covid19 since the study sites were well distributed throughout jordan these findings are likely to be representative of jordans population most of the participants reported that the first covid19 infection was identified in wuhan the capital city of hubei province in china about half of the participants thought that bats were the source of covid19 viruses one of the notable results of this study is that the majority of participants believed that coronavirus is a factory virus with political and economic goals of biological warfare this indicates that there was no clear knowledge about the source of covid19 in the society and further education is required that might help to better understand the source of covid19 and their mode of transition in this study 936 of respondents correctly recognized the transmission modes of covid19 that is indicative of good knowledge this was in agreement with studies carried out by zhong et al 21 abdelhafiz et al 22 and bhagavathula et al 24 which showed that 988 959 and only 39 of respondents correctly recognized the transmission modes of the novel coronavirus this study also showed that the majority of participants obtained knowledge about covid19 from social media similarly a study done in india among medical and allied health science students found that the majority of students obtained knowledge about covid19 from social media 6517 15 and also another study by bhagavathula et al 24 revealed that the participants main source of information was the official government websites followed by social media 23 furthermore a survey conducted in pakistan reported that social media remained the primary source of information among healthcare professionals 24 this indicates that social media and internet sources provided a wide range of information available including unverified biased deceptive information which can easily misguide the public therefore the focus should be on educating and providing authentic information to health science students so that the right information can be conveyed to the community majority of participants in this study believed that the ministry of health publications can provide a good source of knowledge about covid19 and that social media help educate jordanian society on the right practices that reduce the case of infection with covid19 in addition the majority of the participants also believed that wearing face masks did not necessarily protect people from getting infected with covid19 similar to the results of this study only 378 and 297 of people from the us and uk agreed that wearing sterile medical masks can protect against covid19 21 the general public was advised to wear a medical mask which is counted as one of the most effective preventive measures in the general protocol to protect from covid19 infection however the acceptance of wearing face masks might be influenced by cultural differences 14 therefore only a low proportion of people agreed to wear the masks in contrast to public opinion the results showed that 729 of participants were wearing a face mask outside the home furthermore the majority of married people and students are more obligated to wear the face mask outside respectively this study further indicated that the majority of participants believed that clothes worn during gatherings and shopping in the markets must be cleaned at a temperature higher than 45 °c using strong detergents and sterilization materials surprisingly most respondents were females with a bachelors degree and believed that the reason for this was because the virus sticks to the clothes and stays on them for a long period this might be because females are more educated and experienced with degerming of clothes during laundry regarding ventilating and sterilizing their houses daily there was a significant difference between females and males concerning their beliefs females believed that ventilating and sterilizing their house daily helped to prevent covid19 viruses in addition the results indicated almost half of the participants responded correctly that antibiotics are not effective in preventing or treating covid19 however some respondents also thought that antibiotics might be useful in an indian study 533 of the participants agreed that no antibiotic is approved for the treatment of covid19 15 this kind of result indicated that participants are educated and get the knowledge that the use of antibiotics is considered ineffective against covid19 the respondents were divergent on the use of herbal medicines and eating garlic and ginger to protect against covid19 infection similarly 331 of egyptian public also incorrectly stated that eating garlic could prevent the spread of disease 21 the majority of participants who had a bachelors degree believe more than others that drinking medicinal herbs has a role in covid19 prevention also this study assessed public opinion about using drugs to prevent covid19 many participants were not sure about the role of hydroxychloroquine alone and some of them thought it has been used as a preventative therapy against covid19 infection 17 it may be posited that jordanian people need to be made aware of current preliminary recommendations for the symptomatic management of mild covid19 cases ie fluids antipyretics and rest on the other hand many participants knew that azithromycin has been tried along with hydroxychloroquine in the treatment of covid19 infection some physicians have tried or may be using treatments such as chloroquine or hydroxychloroquine accompanied by a ventilator system as a treatment protocol for patients with severe respiratory distress symptoms 16 limitations of the study among the study limitations is the sampling approach which depends on the accessibility of respondents to internetbased services and their disposition to participate in onlinebased surveys in addition the study was conducted purely on the jordanian population and thus the study findings might not apply to other populations in the region and the world therefore additional confirmation studies are needed in the future the limitation of this crosssectional study is the use of a convenient nonrandom sampling approach with a small sample size although the questionnaire assessed jordanian peoples knowledge attitude awareness and practice towards covid19 this study does not assess the reasons behind the lack of some knowledge and awareness toward covid19 furthermore considerations should be given to understanding the healthcare providers knowledge attitude awareness and practice towards covid19 moreover increasing the sample size would also lead to more comprehensive findings conclusion jordanian people have adequate awareness about covid19 females have more knowledge and awareness about global protection protocols against covid19 it has been observed that the majority of participants acquire the information from social media which is an unauthentic resource for obtaining pieces of evidence about diseases and sources of transition furthermore jordanian people show awareness of immunity and drugs that improve the immune response during covid19 infection the use of global international protocols for protection from covid19 and using the documented sources of knowledge about covid19 spreading and infection should be addressed in future through webinars leaflets and educational operations to improve and correct information and practices regarding covid19 license and the budapest open access initiative which permit unrestricted use distribution and reproduction in any medium provided the original work is properly credited declarations conflict of interest no conflict of interest associated with this work contribution of authors we declare that this work was done by jumanah alshawabkeh nidal abu laban nedaa husein and deema jaber and all liabilities about claims relating to the content of this article will be borne by the authors all authors have participated sufficiently in all the different aspects of this work including conception design analysis and interpretation of data drafting the article revising it critically for important intellectual content and final approval of the version to be published open access this is an open access article that uses a funding model which does not charge readers or their institutions for access and distributed under the terms of the creative commons attribution

methods a descriptive crosssectional online survey was conducted in jordan during the covid19 outbreak from march 25th to april 29th 2020 a validated online questionnaire addressing participants current awareness about covid19 pandemics source of information and perspectives of their role data were analyzed using statistical package for social science spss software descriptive analysis data were reported as mean and standard deviations for continuous variables and percentages were used for qualitative variables pvalues ≤ 005 were considered significant results this study involved 409 participants that had a mean age of 262 ± 87 years and 763 were females nearly 677 of the participants obtained their information about covid19 from social media and 166 from governmental agencies furthermore 707 of participants believed that wearing a medical face mask is not necessary to protect against covid19 about 956 of the participants agreed to take covid19 detection tests when they suffer from symptoms related to covid19 infection and 988 agreed to visit the hospital if they have the infectionthis survey has shown the importance of public awareness in the prevention and control of pandemic diseases most jordanian participants have good knowledge of covid19 as a deadly disease that spreads rapidly among the population in a community furthermore the people have awareness of drugs that enhance the immune system this public awareness made jordan one of the countries with reduced number of weekly recorded cases of covid19 at the beginning of the pandemic

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introduction cancer is a growing burden in low and middle income countries 1 2 despite efforts by the who to prioritise tackling cancer inequity hurdles remain due to the limited evidence to inform costeffective decisionmaking and the high expense of cancer control 1 in ghana cancer treatment is focused in large referral centres in major cities with disparity in resources and health worker expertise in rural areas and limited coverage of the national health insurance scheme 3 4 5 6 7 policy efforts to expand cancer services are further hindered when patients prioritise traditional alternatives over orthodox cancer services 8 multiple socialcultural economic and health system factors can influence how patients access navigate and choose suitable cancer care in ghana 3 in addressing this there is a relative lack of public health surveillance data there have been recent attempts to reconcile this 9 but a comprehensive understanding remains elusive one alternative approach is to consider the relevance of theory socioeconomic model and candidacy framework perspectives on cancer treatment access one important way of understanding the complexity and various factors previously described in relation to cancer treatment service access is to consider this in terms of the socioecological model 10 this has been used in many settings to map barriers to healthcare engagement from a systems perspective 11 12 the socioecological model considers the individual within an ecosystem of intrapersonal interpersonal community health organisational and policy influences this has been applied extensively to map systems factors since it was developed by bronfenbrenner 10 including health behaviours in several african settings 11 12 the process of an individual accessing cancer services is dynamic and delays in access can occur at multiple strengths and limitations of this study ⇒ a strength of this study is the combination of purposive and systematic searches and the reflexive approach to developing the search strategy which enabled it to cover a wide range of articles ⇒ additionally the critical interpretive synthesis involved a critique of the literature to identify methodological limitations and research gaps ⇒ however as only published academic articles are included in this study it may overlook other forms of evidence including locally generated and daytoday working understandings ⇒ the interpretation of the evidence will reflect the inherent biases in world view of the lead author open access stages patients may experience barriers presenting at services negotiating the care pathway being offered and accepting treatment a critical interpretive synthesis exploring health access in the uk 13 highlighted that this involves dynamic interactions between the individual the health environment and health professionals the term access often overlooks this dynamism while terms such as uptake provide a narrow view that overlooks patient demand and service navigation afterwards the candidacy framework provides a multistage interacting process of patient access holistically for example negotiation of services is overlooked in asylum seekers and refugees 14 van der boor and colleagues described candidacy in two broad stages access and negotiation 14 candidacy has been applied to understand patientdoctor interactions influencing cancer health seeking behaviours 15 and in an african context 16 this paper builds on the issue of factors relating to cancer treatment service access in lmic settings such as ghana by presenting the findings of an evidence review that was informed by theory the primary aim was to systematically review and critique literature from a systems perspective to understand factors influencing cancer treatment service access in ghana a further aim was to assess the strengths and limitations of methods associated with existing research relating to this topic methods using the retreat framework 17 cis was considered to be the most suitable approach 13 cis has been used in a variety of policy and health service settings 18 19 20 and combines systematic and purposive approaches to identify multiple types of evidence and identify themes following an evidence critique this involves considering how the problem has been constructed underlying assumptions and epistemology and how this has influenced the methodology and conclusions 13 search strategy and literature search the search strategy to find articles on access of adult cancer treatment in ghana was developed using the question framework perspectif timing findings 21 in consultation with an information specialist first primary systematic searches were undertaken this was tested and refined through pilot searches before conducting comprehensive searches in medline web of science cinahl and african index medicus these databases were chosen following university of sheffield librarian advice and after the initial database scoping exercise in medline and google scholar the database search strategy and terms used can be found in online supplemental table 1 initial searches were conducted on 26 march 2021 and the databases were searched for updates on 29 march 2022 search terms were composed of multiple equivalent thesaurus terms and phrases to cover three elements ghana health service accessuptake of services and cancer hand searches were performed using citation followup identified relevant individual journals and in the reference listed of included papers study selection the lead author screened all titles and abstracts using an agreed inclusion criteria while two other authors conducted quality checks of 10 of the sample screened any disagreement was discussed and settled among authors initial screening highlighted ambiguity in the screening criteria which was further refined to ensure consistency prior to formal selection inclusion criteria included only primary research conducted with a 10year time frame to align with ghanas increased policy interest in efficiently expand national health insurance packages 6 initial screening highlighted the need for a focused exclusion criteria which was again informed by the question framework perspectif 21 applying the perspectif framework the phenomenon of interest was defined holistically through the candidacy framework 13 thus article screening sought to include articles relating to access throughout the entire patient pathway the setting included all levels of the socioecological model to provide a systems perspective potentially qualifying abstracts were read in full and only the full texts papers that meet the review inclusion criteria were included and reviewed data extraction and synthesis data were extracted from included papers to facilitate decisionmaking and an audit trail the lead author used a standardised data collection form to extract data from the included studies to eliminate data extraction bias two reviewers checked 10 of the extraction there was no discrepancy observed between the lead author extraction and the sample reviewed key data extracted were setting approach population and sample methods design sampling data analysis cancer and stage studied and the corresponding texts crosstabulated against the socioecological model 10 and the candidacy framework data were collected as line of arguments 13 first order constructs and second order constructs were extracted and separately noted within the framework it was noted where study authors made further inferences and assumptions from data that were not primary findings but relevant to the themes researchers limitations were recorded the data were segregated into qualitative quantitative and mixed methods studies and each interpreted qualitatively a synthesising argument 13 was open access applied to map first and second order findings across studies to interpret the evidence and to create new concepts that draw on the whole body of evidence inferences were mapped across the studies to enable the body of evidence to be critiqued by research question construction methods and conclusions and how these fit into the general findings to identify trends in the literature and limitations with current approaches to bring together themes in candidacy the candidacy framework was summarised into three main stages van der boor and white used two stages 14 however as themes were identified it was noted that treatment acceptance and the interactions around this over time play a pertinent role in the patient pathway in ghana thus the adapted threestage model also notes the importance of the dynamics of treatment acceptance as part of the synthesis process the primary literatures from the data extraction were revisited and reinterpreted with emerging evidence to ensure critical details or limitations were not missed critical appraisal a streamline critical appraisal for major and methodological flaws was conducted using the critical appraisal checklist published in dixonwoods et al 13 the quality of quantitative and qualitative findings was assessed in terms of reliability and trustworthiness 22 in line with the cis articles were not favoured based on quality alone but contribution of rich insights the cis deals with weak evidence through including a critique of methods and approach lead author appraised all the included papers with 10 of the sample being crosschecked by rc patient and public involvement statement no members of the public or patients were involved in this research results search results systematic searches in four databases and in six journals performed in march 2021 identified 312 citation after duplicate removal 203 potentially relevant abstracts were screened subsequently 78 articles were identified for full text screening a further 16 abstracts were identified for full text screening following citation and reference searching twentyeight articles were selected for inclusion flow diagram in figure 1 these comprised 15 qualitative 12 quantitative studies and 1 mixed methods study open access a summary of the articles reviewed is included in the online supplemental table 2 applying the candidacy framework and socioecological model key themes were identified and are presented below the evidence mapping table highlights the candidacy stage and level within the socioecological model that the articles addressed as judged by the lead author accessibility defined through a candidacy lens the candidacy framework 13 proved valuable in assessing how healthcare access has been approached from a holistic perspective treatment acceptance was a key emerging issue where there was a gap in understanding within treatment acceptance there were multiple aspectsdelays accepting interruptions choosing alternatives and incompletion or loss to followup noncompliance refusal for referral and nonacceptance of diagnosis this was a dynamic process although the full candidacy process has been considered in research there were key gaps in how it had been approached and some aspects warranted further exploration seven studies aimed to explore delays with initial contact with cancer services on identification of need yet the reasons for eventual nonpresentation could not be explored in most studies that were clinic based as all patients surveyed eventually reached treatment centres two studies quantified acceptance as having complete followup and treatment completion a further four noted delays and high nonacceptanceloss to followup but did not formally explore them at an individual psychosocial level as this was not within the research aims twelve qualitative studies explored individual barriers to accepting care however this was not always the primary focus but emerged in the findings 23 24 as these were sampled from a clinic they represented patients who eventually accessed treatment so the enablers and barriers in those who ultimately dropped out was unknown therefore indepth qualitative psychosocial information on treatment incompletion was not collected although the literature on acceptance was predominantly breast cancer related there was some limited evidence it occurred in other cancers but the extent and reasons for this were not explored barriers and enablers of cancer service access interpreted through the socioecological model the findings on enablers and barriers to candidacy for cancer treatment were mapped using the socioecological model to consider the ghanaian health ecosystem these are summarised in figure 2 intrapersonal financial barriers inability to afford treatment was reported as a barrier leading to delays in and nonacceptance of care this was also noted by traditional herbalists 25 and health workers 3 yamoah et al 26 found that it encompassed socioeconomic factors travel costs and lost work although two studies indicated it was a greater barrier in those from a low income 27 28 sanuade et al 29 suggested this was regardless of socioeconomic status four studies 23 2830 demonstrated that high cost of medical treatment led to use of herbal and traditional alternatives prioritisation of finances on family led to delays in accepting treatment 23 24 31 financial barriers impacted negotiation of care 31 those from a lower income were more likely to experience longer wait times 32 fears and beliefs about treatment and its outcomes obrist et al 33 found patients who believed in the efficacy of treatment were more likely to complete treatment in single variable analysis although this was not significant in multivariate models where potential confounding factors were controlled for fears and beliefs pose individual level barriers from qualitative finding this included fear of treatment medicines and the outcomes 8 24 28 29 34 for example for breast cancer loosing breasts womanhood female identity 24 28 29 fears around institutional trauma suggested lack of trust health facilities 29 healthcare professions deliberately miscommunicated to avoid patient fear and drop out 35 misunderstanding about cancer signs and symptoms lack of knowledge about cancer signs and symptoms led to delays in seeking medical treatment 8 24 28 31 3638 with breast cancer lumps were not regarded as serious when painless and sometimes considered part of normal tissue 8 24 28 31 this was influenced by beliefs held in the community and within patients social networks 8 31 36 lay beliefs were influenced by the terminology used for breast cancer in the local dialect which led to poor understanding 39 figure 2 key influences on candidacy for cancer treatment mapped against the socioecological model 10 11 12 open access social demographics associations evidence was conflicting as to whether age religion and ethnicity impacted stage of diagnosis wait times and treatment completion which may associate differently in different cancers given different demographics and natural histories 26 32 33 4043 as ethnicities often cluster predominantly in different regions the potential confounding of local health system and environment should be checked in future studies some evidence indicates that lower education is associated with the presenting of larger tumour masses 43 44 and waiting longer for treatment 32 but this was not a consistent influencer and whether it was associated with treatment acceptance was not explored one study exploring treatment pathways for young people with chronic diseases suggested community beliefs were more influential than educational status 36 another found that community beliefs and norms influenced the perceptions of breast cancer regardless of socioeconomic status 39 despite clear financial barriers to treatment there was no evidence that income status and occupation were associated with presentation and acceptance of treatment but low income status was associated with increased wait times in one study 32 interpersonal marital relationships influence treatment seeking qualitative evidence in female cancer suggests husbands influence their wives treatment seeking behaviours and acceptance 8 24 27 29 31 38 39 45 by controlling financial decisions about treatment family prioritisation delayed treatment women prioritised other activities linked to their economic family and social roles such as working for more money treating children and paying school fees these lead to delays presenting for negotiating and accepting treatment 8 23 24 28 31 caring for others meant patients put the needs of others first neglecting their own health this aligns with findings on the unaffordability of treatment close support networks influence treatment access patients understanding about cancer its causes and how they engage with care was influenced by close friends and family 8 23 28 34 3638 45 misinformation could lead to late presentation delay help seeking and use of alternatives 8 23 36 37 for women lack of husband family and friend support delayed treatment seeking 27 45 familial financial support was an enabler for some to seek treatment 23 45 whereas family neglect may impeded access 3 institutional healthcare personnel as gatekeepers to medical and alternative care poor detection at primary health facilities community pharmacy and private settings may have delayed diagnosis 3 8 23 31 36 4446 some women sought over the counter medications for pain management 37 seeking assistance from someone other than a nurse or doctor was associated with a larger mass at diagnosis for breast cancer which could include a diverse mix of pluralist and community supports 44 some health professionals also advised herbal alternatives delaying medical cancer treatment 29 a mixed method study found an inability for facilities to diagnose cancer improper documentation and filing of patient folders and workloadlikely exacerbated by a shortage of healthcare workers trained in oncology outside of major tertiary centres 3 in agreement qualitative studies with patients found misdiagnosis were common 37 38 there were delays due to the complex referral process waiting a long time to get results having to go to many hospitals and laboratories to be diagnosed and consultant rescheduling 37 38 delays between referral and starting radiotherapy were suggested to be due to resource availability while irregular medicine supply also meant patients had to source medicine outside hospitals at high cost 23 47 patients showed negative perceptions of the care system and professionals 27 29 29 45 patients perceived treatment delays due to workforce shortage hospital machines breaking and medicines shortages 29 these beliefs appear to contribute to a lack of confidence and trust in the health system noncompleting patients were more likely to harbour negative views such as that the unavailability of cancer medicines delayed their treatment 33 doubts in the efficacy and disappointment with conventional treatment created barriers to seeking treatment 27 and influenced use of pluralistic treatments 30 fear of radiation led some not to receive clinically recommended treatment 30 community the body of literature showed the strong role community beliefs and norms played in shaping access to cancer care these were interconnected with personal perceptions and health system factors spiritual and traditional beliefs about cancer causes and treatment in an overwhelming majority of the literature patients assigned their cancer diagnosis to spiritual causes which led patients to seek traditional herbal and spiritual treatments delaying presentation and interrupting medical treatment at multiple stages this was associated with financial barriers to conventional treatment 23 28 29 advice from supports such as spouse 45 health workers 29 religious messages 8 29 community networks and beliefs 8 29 31 34 36 39 additionally alternative therapies were often perceived as more available and acceptable seen as efficacious 27 28 39 47 religiosity plays a diachronous role religious beliefs messages and leaders influenced alternative therapy use 8 29 and caused delays 8 29 37 yet religious leaders were identified within patients trusted support networks 8 and their advice facilitated medical presentation 8 24 some studies found the church played a supportive role encouraging women to present at services and providing financial assistance to lowincome families 24 open access gender and identity norms for women with breast cancer mastectomy was associated with a fear of diminished sexuality and femininity which led many women to delay treatment after seeing an oncologist 24 28 29 31 unaddressed fears about fertility loss may have increased dropout 35 however the barriers around identity may differ in other tumours and population groups community networks influenced beliefs and norms common misconceptions beliefs and behaviours held by patients were reinforced by community and social network beliefs 8 29 31 36 interlinked with community beliefs about cancer is self and socially experienced stigma due to the cause of the disease being spiritual a curse misendeavour or the patient being a witch 24 27 39 this led to patients seeking traditional herbal and spiritual treatments while creating shame and secrecy a retrospective survey found patients who did not complete treatment were more likely to answer they do not know if they were fearful of their community response however this likely reflects uncertainty by next of kin respondents who were substantially higher in noncompleting treatment groups 33 policy nhis inclusion of cancer care based on the financial barriers to treatment reported by patients and healthcare workers lack of cancer care inclusion within the nhis was inferred to lead to treatment refusal and delays 3 this was the case for cancers not covered by the scheme 26 42 48 as well as breast 23 24 and cervical cancer 27 40 patients with breast cancer were unanimously frustrated that the nhis did not cover substantial amounts of treatment and discussed the huge financial burden especially of chemotherapy drugs 23 24 this meant some women could not start treatment on time 34 this was aggravated by medicines stockouts 3 23 29 47 requiring purchase elsewhere at additional cost 23 47 not being insured was significantly associated with a shorter wait time for breast cancer treatment 32 which could reflect preferential treatment to those paying upfront due to delays in the administrative process of reimburse nhis funding knowledge of hormone receptor status predicted complete treatment followup as this service is offered at a cost 41 healthcare professionals acknowledged costs were barriers for patients but struggled to broach such topics 35 integration of pluralistic care approaches given the prominent roles of traditional herbal and spiritual care improved integration with the orthodox health system could improve patient access 25 28 thirtyeight per cent of clinical workers surveyed in ghana attribute treatment disruptions to traditional medicines use 3 reported use of traditional healers was a significant predictor of late presentation after other variables were controlled for 44 an assessment of factors associated with treatment completion found visiting a traditional healer was a significant predictor of not completing treatment 33 although alternative support could be concurrent to orthodox medical intervention over 50 of complementary and complementary medicine practitioners surveyed indicated they did not let patients seek other care alongside 25 and 63 of customers said they declined orthodox therapy while using such therapies 30 nevertheless one study found that although 122 seek alternative therapies this only partially explains high rates of loss to followup 41 while traditional herbalists are considered health professionals with some services integrated into the ghanaian health system poor knowledge of cancer causes and symptoms and treatment and reluctance to refer to other services are barriers to providing their patients with timely appropriate care 25 this is influenced by a perceived reluctance collaborate from other health system components 25 mburu et al suggested the interaction between treatment approaches is nonlinear as acts at multiple pathway stages 37 critique of the evidence as part of the cis approach a critique of the literature was conducted to identify themes in methods assumptions theories and analysis to identify methodological limitations and research gaps for further studies a summary of the studies characteristics is displayed in figure 3 this review accurately represents evidence in ghana which has a high breast cancer contribution most studies focus either on presentation delays or treatment interruptions barriers and treatment delays although many studies note treatment incompletion and loss of followup only two assess this directly and they note challenges in data collection 33 41 there are no qualitative studies exploring definitive incompletion eightyeight per cent of studies were based in tertiary treatment clinics in the greater accra and ashanti region so may not reflect those in other regions as 89 of qualitative studies sampled purposively from tertiary clinics this led to biased sampling they omit those who did not attend those who dropped out without contact or cannot reach treatment centres sampling patients in clinics represents those who eventually presented for and accepted treatment barriers could be experienced differently in the underrepresented population as some studies had a small sample and were predominantly christian there was limited ethnographic diversity which may influence generalisability findings on the social demographic traits linked to barriers accessing treatment were inconclusive hypothetical inquiry was found to be common across studies this may lead to error if an individual is not able to accurately predict their behaviour in an unknown situation 49 which may be the case as cancer is stigmatised and not talked about openly 50 further work should explore and seek to understand the impact cognitive bias may have when using hypothetical situations the gaps in research identified are summarised in box 1 open access discussion this study used cis to review multiple types of qualitative and quantitative evidence from literature on access to cancer treatment services in ghana applying candidacy enabled the dynamic and continuous process of accessing negotiating and accepting treatment to be explored within the ghanaian social economic and policy environment it highlighted determinants of cancer treatment service access in ghana are interlinked and within each stage of the socioecological model there is a research gap in understanding the determinants of accessing treatment in the most vulnerable populations due to methodological limitations through this approach we were able to critique the literature highlighting trends in methodology and gaps in evidence for future study the cis enabled detailed contextspecific insights as well as identifying limitations in research approaches data collection and acquisition challenges to inform future research a reflective and iterative approach to broaden the breadth of evidence interpretation and assimilation was taken this was particularly valuable for integrity in research in west african due to epistemic injustice in how knowledge is perceived and interpreted 51 this is the first study to have explored the applicability of the candidacy framework of healthcare access to a ghanaian setting although this has proven valuable in other african settings 16 this model was developed in a uk setting therefore it was important to acknowledge preexisting bias in perspective and thus to critically assess this framing and how it might impact the interpretation of results 51 selecting globalised frameworks can lead to interpretive marginalisation another limitation of the framework was that we found differences in conceptualising and describing patient engagement pathway with cancer services between studies meant that ascertaining candidacy categories for each required researcher interpretation only published academic articles were included in this study which may overlook other forms of evidence including locally generated and daytoday working understandings however this was minimised through open access an iterative approach to include multiple databases targeting local journals and supplementary searches a methodological challenge was the vague and broad nature of terms relating to accessing healthcare thus there was a need to balance breadth of search with pragmatism to formulate a multistep search strategy however this may mean not all relevant literature was uncovered additionally the critical interpretive nature of the review meant the evidence interpretation conducted by the lead author will reflect their inherent biases in world view 22 this review was focused on access to cancer treatment in ghana exclusively so it is uncertain whether the findings translate to other contexts the evidence highlighted financial barriers to cancer treatment access which interacted with cultural factors and societal influences such as norms around managing household finances prioritisation and cultural acceptance of alternative medicines globally catastrophic costs due to noncommunicable disease health expenditure are prevalent in lmics leading to individuals not taking medicines and impoverishment 52 this exacerbates inequities having the greatest impact on the poor and leads to detrimental coping strategies 53 poor patient clinician relationships have been found to lead people to seek traditional medicines alternatives in ghana 54 traditional medicine practitioners were seen to offer more patientcentric holistic care which was more comforting a lack of trust was noted for orthodox facilities which may reflect cultural beliefs as well as past healthcare experiences an evidence synthesis across lmics found modern medicines viewed to be harmful and ineffective suspicion and mistrust of biomedicine lengthened delay and led to alternative use and the impact of this may be exacerbated in the most vulnerable 50 a qualitative exploration of influences on traditional medicines use in ghana found their pull by accessibility and alignment with cultural beliefs whereas scepticism of biomedicine may push people from orthodox healthcare 54 at a community level spiritual beliefs about the origin of cancer interacted with personal perceptions at the individual level notions and beliefs typically held in the community can be ascribed as lay explanatory models of disease in accordance with kleinman 55 lay models of disease can differ from biomedical models based on social experiences and impact how individuals interpret and act on their condition community factors influenced explanatory models for hypertension in rural northern ghana and impact treatment access 56 similarly in this review explanatory models created stigma leading to secrecy and selection of traditional medicines over biomedical intervention at a policy level two key themes where reforms could improve cancer treatment uptake stood out greater inclusion of cancer treatments within the nhis enhanced integration of traditional medicines to provide complementary options to medical care for cancer despite the nhis aim of achieving universal health coverage for all there has been notable disparity with the lowest coverage concentrated in the poor 57 58 multidimensional barriers due to poverty dissatisfaction and distrust of the health service and staff may prohibit enrolment 59 furthermore catastrophic spending due to out of pocket costs remains high 60 the nhis plan seeks to cover a considerable amount of the local disease burden and since its nascence the inclusion list has been revised in response to transitions in disease burden and advancing treatments 61 62 despite breast and cervical cancer in theory being covered 63 it is widely noted women still face considerable financial burden which this study further highlights the burden in men however remains less clearly mapped the high expense of cancer medicines poses a challenge to decisionmakers who must weight costs and benefits when deciding on how to invest health budgets approaches such as the health technology assessment platform recently established in ghana could help prioritise highcost medicines 64 65 another policy area identified in this review was coordination between medical services and traditional medicines studies in ghana have shown traditional medicine users are more likely to be poor and not insured on the nhis 66 the nhis currently provides services through a plural system of public faithbased governmental and private facilities and includes some traditional medicines 57 although lack of harmonisation of traditional medicines with the healthcare system 67 was reported in this study there have been multiple reforms to this end since the traditional and alternative medicine directorate was established under the ghanaian ministry of health in 2001 68 still coordination is hindered by a lack of professional respect from other health professionals 67 cocurrent use of alternative forms of care has been found in pregnant women in ghana it was highlighted the individual psychosocial and emotional support they provide which this study found can be lacking patient interactions with orthodox medicine despite being key for candidacy in cancer treatment 15 69 the african union has calls to recognise the importance of traditional medicines and a global centre for traditional medicines has been established in india 70 71 however there remain challenges in how traditional and complementary medicines are perceived and deemed efficacious barry 72 suggests differently constructed modes of evidence are needed for traditional medicines as scientific evidence through clinical trials offers a reductionist narrowly defined view of evidence that overlooks the role of livedin social experiences advocating for the expanded epistemology of science 73 future policies should seek to improve the affordability and quality of publicly provided medical care while harmonising with complementary treatments that align with community beliefs future research is needed to address the research gaps identified first to understand the extent of treatment nonadherence across all cancers and what individual open access social and health system factors impact this second there are methodological limitations in understanding the views of those who do not attend clinics which may represent the most vulnerable researchers should seek approaches to overcome this which are suitable within the local context twitter laura a gray drlauraagray competing interests none declared patient and public involvement patients andor the public were not involved in the design or conduct or reporting or dissemination plans of this research patient consent for publication not applicable ethics approval not applicable provenance and peer review not commissioned externally peer reviewed data availability statement data sharing not applicable as no datasets generated andor analysed for this study data sharing not applicable as this is a review of literature and no datasets were generated supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

objectives multiple socialcultural and contextual factors influence access to and acceptance of cancer treatment in ghana the aim of this research was to assess existing literature on how these factors interplay and could be susceptible to local and national policy changes design this study uses a critical interpretive synthesis approach to review qualitative and quantitative evidence about access to adult cancer treatment services in ghana applying the socioecological model and candidacy framework results our findings highlighted barriers to accessing cancer services within each level of the socioecological model intrapersonal interpersonal community organisational and policy levels which are dynamic and interacting for example community level factors influenced individual perceptions and how they managed financial barriers evidence was lacking in relation to determinants of treatment nonacceptance across all cancers and in the most vulnerable societal groups due to methodological limitations conclusions future policy should prioritise multilevel approaches for example improving the quality and affordability of medical care while also providing collaboration with traditional and complementary care systems to refer patients research should seek to overcome methodological limitations to understand the determinants of accessing treatment in the most vulnerable populations

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background according to data published by the world bank the percentage of rural populations fluctuates from 19 to 59 depending on the degree of development of the countries in question 1 in spite of these figures however differences in health and disease patterns between rural and urban areas have not been widely studied 2 evidence concerning inequalities in health and mortality between rural and urban settings has reported conflicting results with respect to the source and characteristics of the population 34 with respect to cardiovascular diseases coronary heart disease mortality has been observed to be more prevalent in rural areas 5 and similar results have been published for heart failure although only regarding men 6 whilst the hf incidence rate has declined in recent years its prevalence has increased suggesting that survival over time is longer probably due to better care and treatment 7 nevertheless this improvement in survival is modest 8 and research in hf is considered one of the most important priorities 9 patients classified as new york heart association functional class iiiiv present almost fourfold greater rates of mortality and up to 583 of nyha functional class iv dies after a fiveyear followup 1011 however due to its irregular evolution hf is not usually considered a terminal disease whilst at advanced stages it could be compared to malignant neoplasms 12 although many predictors of mortality among hf patients have been well identified 13 social and environmental determinants are not usually included in predictive models particularly in patients at terminal stages of the disease some studies have shown worse prognoses regarding socioeconomic position 14 social risk 15 health literacy 16 and urban areas of residence 17 even though gaps in the availability of general palliative care in rural areas have been reported 18 information about the differences in the lifetime of hf patients or health services utilization depending on their residence and socio economic level is scarce this study was aimed at analyzing health inequalities and mortality according to place of residence in hf patients at advanced stages of the disease attended in the community by analyzing real world data methods we followed a populationbased cohort of adult patients presenting the most advanced stages of heart failure between january 1st 2010 and december 31st 2014 the inclusion date was taken to be when patients were first registered as having nyha functional class iv in their primary healthcare electronic medical records during the study period nyha functional class iv was considered when patients diagnosed from hf were unable to carry on any physical activity without symptoms of hf or symptoms of hf at rest 19 the whole cohort was followedup for at least 1 year from the inclusion date or until a fatal occurrence took place during the study period information was collected from the primary care electronic medical records through the information system for the development of research in primary care this database contains data from 58 million individuals attended in 279 primary healthcare centers which attend 80 of the whole population of catalonia and it has already been validated for use in cardiovascular research 20 the database incorporates both administrative and clinical data which are encrypted to guarantee the confidentiality and anonymization of the information gathered for research purposes and provides data about diagnoses clinical characteristics comorbidity laboratory and diagnostic tests social and demographic variables and performance in activities of daily living tests to evaluate functional physical and mental status drug prescriptions and primary health care service utilization information regarding the patients vital status is also included and comes from the central insurance register patients with hf were identified using the international classification of diseases tenth revision claim code i50 the icd 10 codes selected to register comorbidities were diabetes hypertension coronary heart disease stroke atrial fibrillation chronic kidney disease chronic lower respiratory diseases and cancer clinical variables laboratory analyses and tests assessing functional were obtained from the patients consultation closest to the inclusion date and missing values were imputed the barthel index which has proved helpful in assessing the functional status of a patient 21 and the charlson index used to predict tenyear mortality and healthcare resource utilization in patients with a range of comorbid conditions 22 were regularly collected during the nurses consultations to determine socioeconomic status among the urban patients we employed the medea index which is an aggregated socioeconomic deprivation model which classify the population living in small geographical areas according to the percentage of unemployment manual and temporary workers and individuals with insufficient education the lowest quintile represents individuals with the most favorable socioeconomic position and the upper one the worst the unit of aggregation was the census tracts which is the smallest territorial unit for which population data are available in our country this index has been proven valid for urban areas although in rural ones it does not discriminate accurately 23 family networks as well as living conditions were assessed through an interview by a social workers or nurses using the gijon socialfamily scale which includes questions about housing conditions family and social relationships and income 24 family network was explored by the following items living with relatives living with relatives living with a partner living alone and living alone we grouped the last two variables and classified family network as living alone or not regarding housing conditions we considered them inadequate when the house had structural barriers humidity or incomplete facilities no elevator or telephone or patients were living in a slum health service utilization was computed as the number of consultations made with the family physician primary care nurse or specific primary care emergency services rural residence was defined when patients lived in an area with less than 10000 inhabitants or the density of population was lower than 150 inhabitkm2 according to the catalan healthcare administration classification 25 the prescription of angiotensin converting enzyme inhibitors angiotensin ii receptor blockers beta blockers mineral corticoid antagonists and loop diuretics was also collected the primary outcome was allcause mortality occurring during the followup statistical analysis continuous variables were described by means standard deviation and median and percentages were used to describe categorical variables variables included in the analyses were sociodemographic clinical and laboratory test data comorbidity consultations made to primary healthcare professionals activities of daily living presence of family networks housing conditions and medication related to hf living in urban or rural residence was the main independent variable and global mortality was the end point of the study the anova test was performed to compare the number of visits according to the different levels of medea deprivation index as a categorical variable characteristics related to mortality and differences between urban and rural patients were first compared using chisquare test or student t test odds ratios were estimated by logistic regression models to evaluate the relationship between urban and rural residence and to evaluate the association between these characteristics the place of residence and mortality multiple imputation models were performed to manage the missing data by using the mice and vim r packages the mice function is based on the conditional specification where each incomplete variable is imputed with a separate model a total of 50 imputations were generated and the final data were obtained with the complete function that generates a complete data set that combines the observed and imputed values cox multivariate logistic regression was used to analyse the characteristics related to mortality and covariates included in the model socio demographic variables and those statistically significant in the bivariate analyses were included in the final model statistical analysis was conducted using r software for windows version 361 vienna austria results descriptive findings we analyzed data from 1148 hf patients in nyha functional class iv mean age was 816 95 of patients were older than 64 years and 61 were women most of the population lived in urban areas and more than 69 were older than 74 years among the total number of patients included 68 presented high comorbidity according to the charlson index and daily living activities were moderately to severely affected in 56 the most frequently associated comorbidities were hypertension atrial fibrillation diabetes and coronary heart disease cardiovascular comorbidity was present in 69 of the patients and 22 presented two or more of these conditions regarding the number of chronic conditions included in the analyses the median was 3 and 62 of hf patients had simultaneously three or more comorbidities betablockers angiotensin converting enzyme inhibitorsangiotensin ii receptor blockers and mineral corticoid antagonists were prescribed in 45 66 and 26 of patients respectively a combination of the three medications was present in 10 whilst loop diuretics were prescribed in 88 during the period of the study patients consulted their family physician on average 22 occasions 20 with their primary care nurse and on three occasions the primary healthcare emergency centers differences between urban and rural patients mean followup until the end of the study or the occurrence of a fatal event was 16 months for urban and 145 months for rural patients respectively although rural patients were on average 2 years older they presented lower comorbidity in spite of not being statistically significant the urban cohort tended to live more commonly alone no differences in cardiovascular comorbidity clinical variables performance in activities of daily living or hf medication were reported between rural and urban patients table 1 describes how in analyses stratified by gender there were no outstanding differences regarding place of residence in any of the variables with the exception of age and the higher percentage of women living alone in the cities we compared primary healthcare service utilization by hf patients according to place of residence and socioeconomic deprivation it was observed that those in the most socioeconomically deprived urban areas tended to use more frequently primary care emergency services than the other urban individuals and even three more times compared to rural ones regarding consultations with the family physician and primary healthcare nurses patients in the most deprived urban areas were the greatest users of the former and this higher utilization was statistically significant in the case of the later overall mortality among the 592 patients who died during the period of the study 488 lived in urban and 104 in rural areas respectively analyzing the number of fatal events during followup the mean rate of survival from study inclusion was 106 and 98 months for the urban and rural cohorts respectively older age charlson comorbidity index chronic kidney disease higher potassium levels and cancer were related with a higher risk of dying in contrast greater body mass index blood pressure glomerular filtration barthel index and hemoglobin were protective with respect to mortality risk when analyzing sociodemographic variables related to mortality we found that being men older living in rural areas and having unfavorable housing conditions were related to higher probability of dying but no significant differences were found among urban patients regarding the area where they lived table 3 shows the differences in mortality according to the fact of living in urban and rural areas older age chronic kidney disease lower levels of blood pressure lower levels of haemoglobine and lower body mass index were more commonly related to mortality regardless the place of residence we observed that in patients living in rural areas the prevalence of stroke among those patients who died was higher whilst in urban patients mortality was higher in those with higher prevalence of cancer lower barthel index and worse levels of creatinine multivariate analyses cox multivariate regression model adjusted by the variables significantly associated both with the mortality and the place of living confirmed that being men older having higher comorbidity and living in rural areas were associated with higher risk of mortality the excess of mortality risk for men was 60 whilst for patients living in rural areas it was 35 discussion in our study based on a community cohort of hf patients at the most advanced stages of the disease we observed that mortality was 35 higher in those residing in rural setting being men aged and presenting higher comorbidity were also found to be related to a greater risk of dying we found an inverse gradient in primary healthcare resources utilization regarding socioeconomic deprivation among urban patients those residing in the most deprived socioeconomic areas had the highest health services utilization compared to the rest of europe the population density in the study region is among one of the highest the distribution is however irregular with more than 40 of the inhabitants concentrated in the metropolitan area of barcelona although a number of small hospitals are distributed across the territory most tertiary hospitals are located in this large metropolitan area which can limit accessibility of rural patients to highly specialized care with respect to place of residence we did not observe differences in clinical characteristics or hf medication prescribed although rural women were slightly older urban patients presented higher comorbidity and reported more social isolation this last finding concurs with a previous study reporting that in a rural environment it is easier to rely on family members 26 although the bivariate analyses found statistical differences in the characteristics associated with mortality depending on rural or urban setting these differences were not clinically relevant we found a considerable number of consultations particularly with primary care nurses among the urban patients living in the most deprived areas in this regard it has already been reported that low income and other psychosocial disadvantages imply greater healthcare resource utilization 27 mortality the higher mortality described for men older hf patients and in those with decreased body mass index chronic kidney disease and lower blood pressure levels concurs with previous studies particularly in the advanced stages of the disease 28 29 30 moreover higher mortality in rural patients is in agreement with a previous study 6 it has been hypothesized that populations residing in urban areas have better health due to easier accessibility to health services in addition to better jobs and income 3 regarding cardiovascular diseases inequalities in rural patients have been reported with respect to access to treatment such as percutaneous coronary interventions which require a longer travelling distance 31 another possible factor contributing higher mortality among rural hf patients in our sample could be the differences reported in the use of health services although we cannot affirm that highest primary care services utilization by urban patients determines longer survival there is a widespread network of primary healthcare outofhours centers nevertheless its distribution and characteristics vary these centers are more complete in large cities offering services such as radiology and laboratory tests which may improve the diagnosis and treatment of complications whilst in the rural areas more complex assistance needs to be provided in small hospitals many rural patients lack daily access to their family doctors which can lead to delay in the treatment of decompensations urban primary healthcare centers are opened between 8 am and 8 pm every day whilst many rural villages do not have general practitioner accessible all days and population must travel long distances to be attended especially in out of hours other factors might be involved in explaining in these differences such as the decision to die at home allows patients to maintain control over their lives the approach to the end of life could be culturally different in a rural setting compared to an urban one a recent systematic review oriented to analyse the socioeconomic factors determining the place of death found that dying at home was associated with living in rural areas but potential causes remain unsolved 32 mean survival time among patients who died in our study was slightly higher among the urban ones nevertheless considering the considerable limitations such patients undergo in their daily activities it may be questioned whether this increased survival time is cost effective in terms of quality of life evidence regarding socioeconomic deprivation among urban residents is controversial hawkins et al employing a geographical composite deprivation index similar to ours and analyzing data from 2000 to 2007 did not describe differences regarding outcomes in hf patients 33 in a more recent article witte et al using the same deprivation index as hawkins reported that socioeconomic deprivation was linked to an increased risk of death in hf patients but only as a consequence of noncardiovascular causes 34 in addition a study performed with the same population in our country showed a protective although not significant effect regarding mortality in the most deprived urban patients 17 the national health service in our country provides universal healthcare which may reduce social inequalities in health by facilitating access to primary care prescriptions and hospitals to populations lacking economic resources but the distribution of healthcare premises in rural and remote areas is conditioned by geographical limitations nevertheless future research will be needed to explain why with no differences in either cardiovascular comorbidities or treatment rural hf patients had the highest mortality rates strengths and limitations although different approaches have been employed to define rurality our definition concurs with others used in similar articles nevertheless due to data limitations we could not fully discriminate the analyses between patients living in the most isolated areas from the other rural ones to ascertain whether differences in accessibility related to mortality are proportional to distance and frequency of healthcare service provision the deprivation index used to study urban socioeconomic differences assumes homogeneity among the population living in the same geographical area but may imply an ecological fallacy because it is possible to find both poor and affluent individuals in the same areas sometimes divided by only one street moreover we lack information in order to discriminate the presence of socioeconomic differences within rural populations and thus considered them homogeneous in terms of social status since administrative databases are used for clinical purposes can lead to missing data in the case of hf some variables such as ejection fraction are not always available to have proper diagnoses according to guidelines 35 nevertheless in our study this fact is not relevant because all patients were at final stages of the disease regarding other possible missing values we performed multiple imputation models to minimize such an effect it would be advantageous to possess data regarding quality of life in order to analyze differences among rural and urban patients the results of our study are potentially valid for areas of the rest of our country with similar characteristics concentrating population in large cities nevertheless in fig 2 hazard ratio and 95 confidence interval for variables predicting mortality adjusted by sex age charlson comorbidity index diabetes mellitus and place of living spain and in europe there are many areas where the rural depopulation is remarkable and the accessibility to healthcare services could be different since our results are based on information coming from more than 80 of the catalan population it is expected to think that they could be extrapolated to the rest prospective studies would be needed not just to observe the presence of differences depending on the place of living but oriented towards specifically analyse their causes to be more precise in measuring the differences in the accessibility the characteristics of patients exploring their perceptions and needs as well as their beliefs and preferences regarding the treatment received at the end of life to our knowledge evidence about differences between rural and urban heart failure patients particularly at advances stages of the disease is scarce this article specifically analyses evidence from electronic health records from elderly hf patients at advanced stages of the disease through a large database conclusions mortality in elderly patients with heart failure at the final stage of hf is higher among those living in rural setting accessibility and inequalities in the healthcare provided with respect to the place of residence may contribute to such differences the increased healthcare services utilization by urban patients living in most socioeconomic deprived areas is not followed by a reduction in mortality health policies should face with social and geographical inequalities to ensure that most part of population have similar access to healthcare provision especially to primary care services which are essential in improving health and reducing mortality authors contributions mam rg jlv en jd and jmvr participated in the interpretation of results the elaboration and revision of the drafts of the manuscript and in the approval of the final version en participated in the data management analysis and elaboration of the last draft and the approval of the final version all the authors gave final approval of the version to be published competing interests the authors declare that they have no competing interests

background social and environmental factors in advanced heart failure hf patients may be crucial to cope with the end stages of the disease this study analyzes health inequalities and mortality according to place of residence rural vs urban in hf patients at advanced stages of the disease methods populationbased cohort study including 1148 adult patients with hf attended in 279 primary care centers patients were followed for at least 1 year after reaching new york heart association iv functional class between 2010 and 2014 data came from primary care electronic medical records cox regression models were applied to determine the hazard ratios hr of mortality results mean age was 816 sd 89 years and 62 were women patients in rural areas were older particularly women aged 74 years p 0036 and presented lower comorbidity mortality percentages were 59 and 51 among rural and urban patients respectively p 0030 urban patients living in the most socioeconomically deprived neighborhoods presented the highest rate of health service utilization particularly with primary care nurses ptrend 0001 multivariate analyses confirmed that men hr 160 95 confidence interval ci 134190 older patients hr 105 95 ci 104106 charlson comorbidity index hr 116 95 ci 111122 and residing in rural areas hr 135 95 ci 109 to 167 was associated with higher mortality risk conclusions living in rural areas determines an increased risk of mortality in patients at final stages of heart failure

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introduction cultural diversity is regarded to be the important asset of nepal located in south asia nepal has multiple languages ethnic groups and cultures people of more than 125 ethnic groups speak 123 languages and follow different religions and have exceptional tolerance among the communities thus multilingualism multiethnicity and multiculturalism are the defining features of our county multilingualism is acknowledged by the constitution and unity in diversity is the basic identity of nepal multiculturalism calls for more intercultural understanding and respect for people with different english language teaching perspectives racial ethnic linguistic and religious backgrounds however scholars claim that one language one nation one culture policy of the earlier governments created a threat to multiculturalism as nepali is the official language and language of the public service commission and many competitive examination it created threat to minority languages education is not only a matter of information transfer but also a cultural phenomenon for enabling teachers to identify racial ethnic linguistic and religious backgrounds multicultural understanding is necessary multicultural education provides opportunities for people of all races to get education in respectable environment in this reference sherpa concedes that multiculturalism encourages people of various communities live harmoniously in society thereby enhancing the value of cultural diversity and ensuring human rights the indigenous activists have been demanding their rights for the protection of their language culture script and literature they also have been demanding the right for educating their children in their mother tongues claiming that these indicate their identity after the peoples movement in 2006 the issue of diversity has been raised by minorities and became a major political issue the prime concern of the unions affiliated with indigenous nationalities is associated with the protection of their culture in general and issues of rights discrimination and social justice in this reference incorporating multiculturalism in teacher education could be a step towards emancipation and social justice this paper aims at exploring the multicultural issues in teacher education curriculum of bachelor of education under tribhuvan university the research questions for this study are review of literature a brief overview of teacher education in nepal the history of formal teacher education is not long in nepal the first organization for providing formal in service and preservice teacher education in nepal is tribhuvan university after knowledge on language and basic theoretical orientations apart from the regular degreebased programmes agencies of the ministry of education run various inservice teacher development programmes and training apart from these professional organizations like nelta have been providing short term and needbased training for the teachers but the researchers question whether preservice teacher education programmes enable teachers for addressing the possible difficulties in ethnically racially socially and linguistically diverse classrooms whatever may be the expert opinion both in service and pre service teacher education contribute for teacher professional development teacher education curriculum and multicultural education teacher education enhances the professional capabilities of the teachers strengthening their teaching skills and aptitudes by exposing them with latest content and methodological ideas however teacher education curricula are criticized on the ground that they dont prepare teachers to address the need of the next generation of students broadly speaking teacher education can broadly be classified under two categories preservice and inservice preservice teacher education develops the entering behaviour of the teachers the changing contexts such as new courses and curriculum new methodology and so on can create challenging situations for the teachers and the teachers can face such challenges through teacher education programme similarly all the inservice teachers have to take teacher professional development courses and these courses aim to develop the language proficiency and methodological skills of the teachers however such courses do not aim to develop a critical awareness of the teachers on the existing social historical political and cultural realities that is to say justice oriented education is possible with incorporating essentials of multiculturalism in teacher education curriculum as teachers are primarily responsible for implementing multicultural education in the classrooms teachers need to be acquainted with the various aspects of multiculturalism in this reference sleeter concedes that preservice teacher education should enable learners to identify cultural diversity within the nation and so all the teacher education programmes need to be guided by multicultural teacher education to develop children and youth to develop the skills which the world requires gay and howard also stress on the incorporation of elements of multiculturalism in preservice teacher education and focus on the need for extensive preparation as a racial cultural and linguistic divide between teachers can be mitigated by preparing preservice teachers to work in ethnically diverse classrooms quality education enables the learners to raise the issue of justice and equality in this regard starkey concedes that the basic aim of education is to develop civilized citizens having the norms of peace human rights equality and justice a tolerant and trustworthy culture can be created by the schools which can be seen as a mechanism for controlling society thus multicultural education seems to be relevant as it tends to raise a voice for equality human rights justice and democracy in nepal society is characterized by diversity and curriculum and instruction should address the diverse need of the people since teacher education is a form of training for prospective teachers it should directly reflect students needs and expectations as school education is the intersection of students homes and culture it is necessary to incorporate multicultural education in education the cultural strengths of the students can be empowered through multicultural education multiculturally responsive teaching is often considered as a pedagogical paradigm that enables teachers to utilize students cultural strengths in hisher teaching this lies on the assumption that language and culture are interrelated and the existence of one lies on the existence of the other thus learning is influenced by culture and culture impacts identity construction in this reference bruner asserts that cultural setting influences learning as well as thinking as they are sculpturedependent and curriculum should not be designed without considering the culture or the students moreover learning style is also influenced by the culture of the learners to which they belong thus the teacher needs to foster culture and value its diversity through instruction and multicultural teacher education forms background for it multiculturalism and issue of social justice the issues of justice equality human rights have been prioritized in educational programmes and curriculum education has been associated with the issues of social justice marginalizing women economically backward community and social exclusion of the dalit community one major issue in multiculturalism and social justice in nepal is language policy and medium of instruction and endangerment of minority language due to the government policies and the local practices language policy of nepal have been formulated in the light of the economy ignoring the local realities and interests of the disadvantaged communities in terms of class ethnicity gender and region communities although policies and legal documents prioritize mother tonguebased education in practice it has been overshadowed by economic and political reasons preference towards linguistic homogeneity might be an injustice to minority communities which ultimately create socioeconomic inequalities mccarty et al argue that the education policy of a nation might be responsible for the marginalization of a certain linguistic community thereby creating learning difficulty due to the medium of language policy moreover the medium of instruction issue is associated with the achievement of the students as educational language policies might create linguistic inequalities language policy should be understood within the larger sociopolitical context of which they are part nepal government has adopted the policy of one language one nation policy in the past and this has created inequalities in the languages thereby empowered the nepali language in education and administration the issue of social justice equality equal access to education and opportunity became dominant after the legitimation of private education moreover issues like education as the basic right free and compulsory education etc are also concerned with social justice the language policies have created inequalities as english and the nepali language exercised excessive space and privilege in education plans after 1990 nepal has adopted a multilingual language policy in education however effective implementation of mother tongue education has not become possible due to the lack of teachers and strong teacher education programs ministry of education has introduced the mother tonguebased multilingual education program in 2007 insisting on the use of students mother tongue as a medium of instruction up to grade 3 though this was a huge step for protecting linguistic and cultural diversity in nepal due to lack of teachers resources and support from the state and power of english medium attraction of public it could not be successfully implemented extensive use of english as a medium of instruction in school education has been contributing to social inequalities marginalized communities such as dalits in rural nepal are deprived of educational opportunities and in certain cases they have to quit school in certain instances public schools charge an extra fee for english medium instruction due to which many students have been deprived of education which is against the principle of education for all one attempt to mitigate the inequality can be the implementation of mother tonguebased education in nepal 123 languages are spoken as the mother tongue but the government of nepal has published textbooks only in 22 mother tongues and children reference materials in 15 mother tongues the issue of multilingualism has been advocated by the activists of indigenous nationalities similarly nepals school curriculum states that local languages culture and knowledge should be included in education moreover peace security human rights are also emphasized in the framework diversity is the basic feature of present society multicultural education aims at educating the students on the issues of diversity it also aims at developing alternative teacher education for developing manpower that works for ending all forms of injustices and oppressions to ensure justice drawing from critical pedagogy critical literacy and power relationships dhillon and halstead concede that multicultural education is based on liberal principles there are four basic principles of multicultural education cultural pluralism social justice and racism sexism and discrimination affirmation of culture in the teachinglearning process educational equality thus the multicultural education aims at enhancing justice based education multicultural education is based on the liberal and emancipatory vision of critical pedagogy and concerned with the empowerment of minority cultural groups the issues that contributed to the emergence of multicultural education stands on the mother tongue of minorities oppressed races religious diversity and other disadvantaged groups and fulfilment of the demands of such specific groups the issue of cultural diversity or assimilation is the concern of multicultural education the emergence of the concept of multicultural education goes to the american racial discrimination between black and white as people demanding the rights were charged to be racists multiculturalism deals with the notion of cultural identity and has to do with the links between culture power and discrimination art music painting etc of the various groups form the subject matter in multicultural classrooms it tries the issue of different ethnic groups living side by side but has their language culture race or religion moreover the inclusion of such content in the curriculum enhances their pride thus multicultural education deals with the concept of culture the role of education in cultural identity the concept of pluralism in a multicultural society as diversity is the societal pride liberal multiculturalism respects the cultural diversity and the need of children to get an education in a pluralist society freedom and equality are the two basic principles of multicultural education multicultural education raises questions against ethnocentrism cultural domination racism stereotyping and discrimination it aims at educating children from different cultures together in a safe inclusive learning environment respecting all the religious or cultural diversity so that the school becomes a miniature society in multicultural education students from diverse cultures learn and interact together students belonging to diverse cultures are encouraged to engage in the rational debate yet value diversity multicultural education prepares students ready for taking challenges in a democratic pluralist society and attempts to create awareness against all forms of racism biases and ethnocentrism students study religion literature art history music of different cultural groups critical multicultural education aims at mainstreaming marginalized groups to empower and acknowledge their voices to address diversity equity and social justice through education as nepal is a multiracial multilingual and multicultural country there is enough justification to implement multicultural education in our academia multicultural education is an approach to school reform and a movement for social justice equity and democracy it aims at restructuring schools to impart knowledge attitudes and skills in a diverse nation and the world it attempts to maintain equity for members of different cultural and socioeconomic groups and to ensure their participation and maintain their cultural identity advocates of multicultural education opine that only knowledge and skills are not enough in diverse groups however banks opines that in multicultural education there is a huge gap between theory and practice and theory development exceeds its practice thus torres and tarozzi advocate multicultural education based on social justice for avoiding all forms of contradictions critical pedagogy and multicultural education as multicultural education focuses on justice based education it has close link with critical theory multiculturalism draws from critical pedagogy critical theory critical race theory and poststructural theory and antiracist theory critical pedagogy aims at empowering the students to question all forms of oppression and encourage them for liberating themselves from all sorts of oppressions critical pedagogues opine that knowledge is never neutral and is controlled by power and pedagogy curriculum and textbook reflect biased knowledge for fulfilment of the interest of powerful and elite groups this shows that texts included in schools might represent powerful or elite culture multicultural education is antibiased education and includes literature music arts of various cultural groups thus multicultural education is also an effort to enhance critical pedagogy multicultural education in the context of nepal multicultural education is appropriate in a multiracial multiethnic and multicultural country like nepal as stated earlier multicultural education aims at incorporating the texts that reflect the art culture music and religion of various communities it is significant in the context of nepal multicultural education acknowledges the culture and religious practices of various communities and should pave towards inclusive education multiculturalism rests on the ideals of social justice equity and critical pedagogy and schools should impart an education that enables students to end all forms of racial discrimination so multicultural education is the move for empowering the educational system in nepal in which all children have equal status in the school thus it is an approach towards social justice culturally diverse communities in nepal have a special significance of multicultural education as unity in diversity is the basic feature of nepali society multicultural education is important to include all minority groups in the mainstream and avoid all forms of racial linguistic and cultural discrimination after peoples movement ii nepal has adopted a generous policy towards the culture and tradition of the minority communities so the constitution of nepal 2015 has provisioned the fundamental rights for the promotion of different cultures and in later years the government has declared holidays in the festivals of different marginalized communities and minority religions so we can say that multicultural education is relevant in the context of nepal methodology this paper is based on the secondary sources and the study is qualitative and used the document analysis as the analytical tool as suggested by bowen to explore the various practices for multicultural education in nepal i have made a close review of bachelor curriculum of english education under tribhuvan university additionally the scholars publications were consulted to make a review on various aspects of multicultural education moreover i have studied and reviewed the selected publications to achieve the determined objective of the study framework for data analysis multicultural education aims at fostering justice oriented education banks opines that the aim of multicultural education is to provide equal opportunities to the students irrespective of their ethnicity gender class and other cultural aspects in the similar vein demir yurdakul opine that multicultural curriculum is designed in such a way that its objectives include the aspects of human rights and empathy on cultural diversity its content is based on themes of human rights and cultural diversity learning environment based on various aspects of culture and evaluation process is based of reflective thinking thus the present study evaluates the b ed english education curriculum based on the outline suggested by demir yurdakul results this study aims at evaluating english education curriculum of bachelor in english education recommended by deans office faculty of education tribhuvan university nepal with multicultural perspectives in terms of curriculum objectives content learning strategies and evaluation bachelor level english education curriculum structure of tribhuvan university at present bachelor level curriculum is based on annual system and it runs for four years the bachelor level english education curriculum can be grouped into three categories as per the nature of the courses a courses on nature of language and language pedagogy and research such as foundations of multiculturalism in english education curriculum in terms of curricular objectives in terms of course objectives reading courses objectives explicitly depict multiculturalism the course reading writing and critical thinking aims at developing students as the critical thinkers which lies in the core of multiculturalism in the same way the course expanding horizons in english of second year aims to broaden the students worldview and present glimpse of different sociocultural realities it also aims to familiarise students with the issues of human rights and freedom and to enhance students reading skills in the themes of reconciliation and peace likewise the course critical readings in english aims at integrating content knowledge with the higher order thinking skills such as logical reasoning critical appreciation and synthesizing through reading and writing it also aims to motivate them to read varieties of texts to develop critical thinking skills apart from these courses other course objectives do not explicitly aim at development of multiculturalism though other curricular elements reflect the essence of multiculturalism multiculturalism in english education curriculum in terms of content content is the next major component of curriculum and can reflect the focus of a curriculum in terms of content the courses we can group the courses in two categories technical courses and reading courses the technical courses are concentrated to imparting content knowledge although course content does not adequately reflect multiculturalism the substances of curriculum reflect multicultural issues such as justice and equality through methods and evaluation strategies multiculturalism in english education curriculum in terms of content as stated in the earlier section the reading courses are comparatively stronger in fostering multiculturalism with reference to content in reading writing and critical thinking intercultural communication section deals with cultural differences and develops empathy and respect to all the cultures similarly gender roles section of reading imparts the feeling of gender equality while the last section under reading includes the content that encourages the prospective teachers to respect various occupations out of seven units of the course critical readings in english the first unit diversity technology and education directly addresses the multicultural issues and the lessons in this unit highlight the issues of justice human rights diversity as resource and respect to the diversity similarly the fifth unit deals with the issues of gender equality which directly reflects multiculturalism additionally the course expanding horizons in english contains the texts on feminism post colonialism postmodernism and these themes reflect equality justice and human rights and reflect multiculturalism the unit human rights and freedom includes the texts that raise voice for justice and human rights apart from the reading courses the course english language teaching methods and practices includes critical pedagogy as an approach to language teaching which lies in the heart or multiculturalism moreover the course includes the strategies for rapport building classroom management student behavior management which strengthens the essence of multiculturalism the fifth unit of the course literature for language development deals with the theories of literary criticism and enables the learners to have critical awareness against racial cultural and gender discriminations and oppression moreover different literary texts directly raise voices against oppressions multiculturalism in english education curriculum in terms of teaching learning strategies in terms of teaching learning strategies prescribed in the curriculum almost all the courses include mainly similar teaching strategies the activities such as collaboration cooperation and empathy among each other and techniques such as discussion group work also promote multiculturalism and justice oriented approach research based collaborative approach prescribed research methodology in language education strengthens the equity which is the basic element of multicultural education multiculturalism in english education curriculum in terms of evaluation as discussed earlier multicultural education seeks reflective thinking in evaluation the courses of b ed english education suggest practical and theoretical examination as mostly evaluation is external the questions of board examination of tu have to be evaluated for assessing the multilingual characteristics however the practical examinations in foundations of language and linguistics english for mass communication and research methodology in language education require research and collaboration that require reflective thinking in the part of the learners discussion the study result reveals that the reading courses of existing teacher education curriculum of b ed has enough instances of multiculturalism in all components of curriculum compared to other courses as the crux of curriculum and its essence lies in curricular objectives the objectives of reading courses are found to be in accordance with the essence of multiculturalism as the objectives emphasise to respect human rights empathy and cultural diversity this coincides to demir yurdakuls version regarding multiculturalism in curricular objectives and reading courses explicitly stregthen the multiculturalism and aware preservice teachers towards social justice based on objectives content of a certain course is determined the content of reading courses include the lessons on peace human rights equality and justice as suggested by apple and starkey regarding the content reading courses have enough coverage on culture empathy diversity and respect to disability as the essentials of multiculturalism this seem to respect critical and justice based education as per the position of and language policy outlined by the constitution of nepal the findings also responded the concern of gay howard that preservice teacher education programmes should enable teachers for addressing the possible difficulties in ethnically racially socially and linguistically diverse classrooms as reading coursed in b ed are prepared on the ground of arousing multiculturalism in the students similarly the findings seem to resemble with the stand of sleeter that preservice teacher education should enable learners to identify cultural diversity within the nation as the existing preservice teacher education programme produces the required human resources for formal educational institutions of the country multicultural awareness enables them to respect cultural diversity of the country as indicated by the number of ethnic groups mother tongues and religions in the latest census result the content and curricular objectives of the reading courses have enough coverage of cultural diversity thus the courses of b ed educate pre service teachers on the issues of diversity as stated banks the nature of content embeded in reading courses tend to empower marginalized groups as opined by lydiah nganga as stated by ali ancis multicultural education enables students to end all forms of oppressions and ensures justice the content of the reading courses seem to be selected in accordance to their position moreover the findings coincides with the version of blake et al that multicultural education should create awareness against all forms of biases and oppressions however it is necessary to examine the implementational aspect whether multicultural education prepares students ready for taking challenges in a democratic pluralist society and attempts to create awareness against all forms of racism biases and ethnocentrism as opined by and strengthen social justice by minimising the contradictions as outlined by torres and tarozzi thus the finding of the present result resembles with earlier researches conducted in various contexts and theoretical stands introduced by various scholars but it is necessary to further investigate the classroom practice to examine the gap between theory and practice and theory development exceeds its practice as banks stated his skepticism in this regard conclusion the analyses of multiculturalism in teacher education curriculum shows that trend of teacher education programme has shifted towards multiculturalism as discussed in the earlier section multicultural essentials are found in reading courses and most of these courses have been introduced in the recent decades in teacher education programmes this paper assessed multiculturalism in teacher education curriculum of b ed based on curricular goals content learning facilitation and evaluation through document analysis the result shows that multiculturalism has enough space in teacher education curriculum mainly in reading courses explicitly in terms of objectives and content while other courses include its essentials in learning facilitation and evaluation this implies that teacher education curriculum in tribhuvan university respects the norms of multiculturalism and oriented towards a nondiscriminatory transformative and emancipatory direction and respecting all cultures paves our nation towards peace justice and inclusive democracy which are the basic features of our constitution however this paper did not evaluate multiculturalism in terms of classroom practice and practical and theoretical examinations further studies can be conducted to explore these issues appendix a english education curriculum bachelor level english education curriculum structure is as follows b ed first year

multicultural education is transformative emancipatory and justiceoriented as multiculturalism is the defining characteristic of nepali society and the basic identity of nepal the relevancy of multicultural education can hardly be exaggerated the constitution of nepal 2015 has also acknowledged unity in diversity as the basic feature of the country so multiculturalism needs to be incorporated into nepals educational system and teacher education programme in this context this study aims to explore multiculturalism in teacher education curriculum of tribhuvan university and outlines the basic features of multiculturalism and assesses the present teacher education curriculum of english education in b ed under tribhuvan university in terms of multiculturalism analysing the different components of english education courses of b ed in english education it is concluded that multiculturalism

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introduction indonesian migrant workers or now known as indonesian migrant workers contribute to central javas economic growth through increasing labor productivity indonesian migrant workers from central java not only have low education who go to work abroad but indonesian migrant workers from central java with higher education also work abroad one of the intentions of indonesian migrant workers from central java to work abroad is to earn a higher income than the income from working in indonesia in june 2022 the total number of indonesian migrant workers stated that the level of human capital externalities ranged from 3 to 5 percent this means that a oneyear increase in the average length of schooling of workers will increase wages by 3 to 5 percent theoretical basis a similar study on human capital externalities has been carried out by moretti by building a model that examines the external impact of education on land prices and wages empirical study of moretti states that companies located in cities with growth of college graduates will increase productivity faster compared to similar companies located in cities with slower college graduates the estimation of the difference in productivity between cities with high human capital and cities with low human capital occurs because of the difference in wages in the two cities in this case manufacturing companies will gain more profits if the presence of human capital is closer both geographically and economically the novelty of this study is that this study adopts the economic growth model of mankiw et al who developed the economic growth model of solow the economic growth model of mankiw et al moran index value is between 1≤i≤1 this study adopted the local moran index statistic from anselin the moransindexstatistical model of spatial autocorrelation is locally written where 𝑰 𝒊 𝒙 𝒊 𝑿 ̅ 𝑺 𝒊 𝟐 ∑ 𝒘 𝒊𝒋 𝒏 𝒋𝟏𝒋≠𝒊 1 𝑆 𝑖 2 ∑ 𝑤 𝑖𝑗 𝑛 𝑗1𝑗≠𝑖 2 𝑛 1 𝑍 𝐼 𝑖 𝐼 𝑖 𝐸 𝐼 𝑖 √𝑉 𝐼 𝑖 𝐸 𝐼 𝑖 ∑ 𝑤 𝑖𝑗 𝑛 𝑗1𝑗≠𝑖 𝑛 1 e 𝐼 2 𝐴 𝐵 𝐴 𝑛 𝑏 2 𝑖 ∑ 𝑤 𝑖𝑗 2 𝑛 𝑗1𝑗≠𝑖 𝑛 1 𝑏 2 𝑖 b ∑ ∑ 𝑤 𝑖𝑘 𝑤 𝑖ℎ 𝑛 ℎ1ℎ≠𝑖 𝑛 𝑘1𝑘≠𝑖 𝑏 2 𝑖 ∑ 4 𝑛 𝑖1𝑖≠𝑗 2 𝑛 𝑖1𝑖≠𝑗 2 𝑉 𝐼 𝑖 𝐸 𝐼 𝑖 2 𝐸 𝐼 𝑖 2 note x is the average value of x x is the observed variable wij is an element of the spatial weight matrix that connects the observations of districtcity i with neighboring districtscities j by using an inclusive distance approach based on the xcoordinate point and the ycoordinate point of a districtcity 𝐼 𝑖 is local moransindex statistic n globally of spatial autocorrelation model spatial autocorrelation occurs when the spatial distribution of the studied variables shows a systematic pattern positive negative spatial autocorrelation occurs when geography tends to be surrounded by neighbors with the same or different values of the variables studied in this study morans i statistic was used to detect spatial autocorrelation in the data morans i statistic is the most widely used measure to detect and explain spatial groupings not only because of its interpretive simplicity but also because it can be decomposed into local statistical forms by providing graphic evidence of the existence of spatial groupings globally spatial spatial autocorrelation is also used to measure covariance or correlation between the neighbors of the observed variables so that information will be obtained about the similarity of observations and similarities between locations this study adopted the global moran i statistics from dube and legros anselin the global morans index equation is written 𝐼 𝑁 𝑆 0 𝑤 ∑ 2 𝑁 𝑖1 note 𝑁 is amount of time observed 𝑆 0 data standardization 𝑥 observed variable 𝑖 observed variable moran index value is between 1≤i≤1 significant decision making if h is rejected it means that there is an autocorrelation between 29 regencies and 6 cities in central java province the approach to the distribution of the observed area xi assumes that the observed data values are normal this study identifies local morans i by reading the positive or negative sign of the local morans index through the distribution approach of the local morans index the approach to the distribution of the observed area x assumes that the observed data values are normal this study identifies the global moran index by reading the positive or negative sign of global morans i through the distribution approach of the global morans index research results and discussion implications and limitations researchers suggest that economic growth be used as a proxy for income per capita with a time span that is adjusted to the batang regency 0001 0001 0028 0000 0007 blora regency 0002 0002 0023 0014 0016 boyolali regency 0000 0001 0001 0011 0003 brebes regency 0000 0001 0068 00142 0133 magelang city 0000 0002 00133 0019 0011 jepara regency 0000 0001 0001 0004 0011 karanganyar regency 0001 0001 0005 0004 0000 kebumen regency 0001 0001 0005 0000 0003 kendal regency 0001 0001 0007 0149 0014 klaten regency 0001 0001 0011 0004 0003 magelang regency 0001 0001 0001 0002 0003 pati regency 0001 0001 0007 0016 0000 salatiga city 0000 0000 0037 0015 0007 pekalongan city 0002 0002 0026 0018 0011 semarang city 0994 0994 0150 0017 0004 surakarta city 0001 0001 0165 0008 0000 from central java in 2010 with a higher education level is spread or divergent the pattern of spatial interaction of indonesian migrant workers from central java with a higher education level randomly from 29 districts and 6 cities in 2010 because there is no unclear feature pattern

indonesian migrant workers tki or now known as indonesian migrant workers imw contribute to the economic growth of central java province through foreign exchange earnings and increasing work productivity the purpose of this study is to analyze the spatial interaction patterns of imw locally and globally this research method uses a euclidean distance weight matrix approach to calculate the local moran index and the global moran index the novelty of this research is to consider indonesian workers or imw with higher education the conclusion of this study is that the results of the local moran index empirical research identify that there are similar or dissimilar patterns of spatial interaction within in group in cilacap regency brebes regency kendal regency however in 2021 indonesian migrant workers imw from central java identified a pattern of spatial interaction within in group both similar and dissimilar in the positions of cilacap regency and kendal regency changes in the local morans index of indonesian migrant workers imw in 2010 and 2021 were allegedly due to the placement of the number of indonesian migrant workers imw to the destination country which was limited in 2021 initially indonesian migrant workers imw in 2010 were indonesian migrant workers imw its placements are in 27 countries decreasing to 17 countries in 2021 the results of empirical research on the negative global morans i coefficient on indonesian workers imw with higher education from 2010 to 2021 identify that the spatial interaction pattern of indonesian workers imw with higher education in central java province is divergent or spreads from districtscities to districtcity

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introduction the highest burden of new hiv infections has been reported in adolescents and young adults between the ages of 13 and 24 years with 371 of the new hiv infections occurring in this age group in the united states 1 among the youths in this age group 87 of the individuals diagnosed with hiv infection were reported to be young men and 51 of these young men were identified as african american while 25 of these young men were identified as hispaniclatino 1 with the rapid increase in the usage of social media over the last 15 years twitter has emerged as a popular social networking platform studies have shown that twitter is used by 32 of the adolescents and 44 of the young adults with black youths reporting higher levels of use than their white and latino peers 23 since twitter is used to discuss healthrelated and riskrelated topics 4 5 6 this platform offers a distinct opportunity to investigate the attitudes beliefs and behaviors of the youths via their publicly shared posts that they have created or to which they have responded this unique content may provide additional insights into the sentiments and discourses of youths 7 beyond what can be identified in traditional formative research methods particularly at the national level analysis of twitter for example might offer insight into the hivrelated beliefs and attitudes of youths of different racesethnicities and help inform interventions that are designed to curb the hiv epidemic among youths the popularity of twitter and the high volume of public tweets provide unprecedented access to discourses about sexual health and hiv by youths across a country although youths use social media platforms such as twitter to share and seek sexual health information and to communicate with romantic and sexual partners 8 research on tweets related to alcohol marijuana cancer and vaccines has shown that twitter is also used to promote risky behaviors spread misinformation and reinforce hivand sexually transmitted infection related stigmas 45910 several studies have also considered social media messages as surveillance data to monitor the incidence of influenza depression zika virus infections and substance use 11 12 13 similar techniques have been used to assess the associations between social media messages on sex and hiv and the risk behavior and hiv incidence 14 several studies have shown evidence of a correlation between hivrelated tweets and hiv prevalence in a population 81415 two studies 1415 showed that futureoriented and actionbased tweets regarding hiv were associated with decreased incidence of hiv infections at the county level in the united states in contrast young et al 8 found that there was a statistically significant positive association between hivrelated tweets and hiv prevalence however these studies 81415 did not distinguish between the source of the tweet instead they combined tweets from individual users and institutions such as public health agencies in their analyses importantly studies on hiv and social media focus on certain keywords such as sex hiv testing and discrimination although the use of these keywords is useful for examining the associations between hivrelated tweets and hiv prevalence studies often have reduced sensitivity to retrieve relevant tweets for analysis and intervention 16 since the abovementioned studies have provided promising evidence that tweets may be associated with hiv risk there is a need for indepth contextualized analysis of twitter messages on risky sexual behavior and health including analyses of message source variations therefore the goal of our study was to explore how twitter activity is related to hiv incidence and whether message characteristics such as content and source can reveal the incidence of hiv infection in a population and the future risks associated with hiv twitter messages may serve as a signal of the realtime dynamics in hiv epidemiology in this study we combined indepth content analysis of hivrelated tweets with automated machine learning techniques to analyze the countylevel associations between hivrelated tweets and new hiv infections in the united states methods sample using the twitter fire hose application programming interface which provides broad access to public twitter data we drew a random sample of 1 of publicly available tweets posted between january 1 2016 and december 31 2016 we sampled tweets from users who tweeted at least 500 words in 2016 and who were geolocated in a county in the united states to determine the geolocation we used two types of data tweetspecific latitudelongitude coordinates and the selfreported location information in twitter user profiles the distribution of the geolocated tweets by county approximate the us population density 17 duplicate tweets bots and nonenglish tweets were removed 1819 after we produced age and gender affiliation estimates for each user with hivrelated tweets based on our tested algorithms 2021 we limited our sample to users with predicted age and predicted gender using previous literature 22 and input from our young researchers we developed a keyword list of hivrelated terms such as hiv aids hiv testing condoms multiple sexual partners sti risky sexual behavior and preexposure prophylaxis prep is an effective hiv prevention medication taken prior to exposure to the virus this keyword list was used to identify relevant tweets and we extracted 9707 hivrelated tweets from 6439 users from the agegender stratified sample we also removed pornographic tweets by developing a classifier to identify pornography and excluded those tweets from our data set our final data set included 6949 tweets by 1541 young male adults and male adolescents in the united states and these tweets contained at least one relevant keyword figure 1 shows the number of messages and users retained at each step of the above described process content analysis data analysis was conducted with a sample of hivrelated tweets posted on twitter we manually coded a sample of hivrelated tweets by oversampling tweets with hivspecific keywords to accomplish this we grouped our keywords into 2 broad categories hiv preventionspecific tweets and general sexrelated tweets we initially included a third category namely riskrelated which included risk behaviorpromoting tweets however we excluded this category from our analysis owing to the small number of tweets in this category from the final data set we took the full sample of 1577 preventionrelated and a 175 random sample of general sexrelated tweets yielding 940 general sexrelated tweets for manual content analysis the final data set was coded by 4 expert coders for 19 nonexclusive categories to capture the context we expanded the coding unit beyond the initial tweet the coders read the 5 tweets that proceeded from the tweet and the 5 tweets that followed the tweet they also reviewed the images or webpages linked to the tweet the coders achieved reliability by using a separate training data set of tweets which was created through the same procedure used for the sample data set we used a training set to train the coders without depleting the main data set during training the coders reconciled the differences in the code interpretations and coding approaches as a team after the coding schema was finalized the 4 coders achieved intercoder reliability on key constructs assessed with an intraclass correlation at 080 or higher approximately 20 of the final data set was coded by at least two coders measures the hiv incidencethe outcome variablewas assessed as the number of new cases of hiv infections in a given county in 2017 these data were sourced from the centers for disease control and prevention atlasplus data platform 23 counties with suppressed data owing to low case counts were assigned a value of 2 which represented the midpoint between the lowest possible suppressed value of 1 and the highest possible suppressed value of 4 twitter messages were classified into the following 3 categories in 2016 riskspecific twitter activity preventionspecific twitter activity and hivspecific twitter activity riskspecific twitter activity is the sum of all the tweets categorized with a riskrelated code in a given county per 100000 residents preventionspecific twitter activity is the sum of all the tweets categorized as preventionrelated in a given county per 100000 residents hivspecific twitter activity is the sum of the riskspecific and preventionspecific twitter activities in addition to the tweets that were tagged as related to lgbtq content all users in our data set were identified as either an individual or an institution based on the manual review of the user profile and recent posting activity institutions included public health agencies social service organizations and advocacy groups and typically included the organization name in the username or user description our final measures of the tweets consisted of 3 twitter activity categories from individuals or institutions resulting in 6 twitter variables we accounted for 3 geographic control variables hiv prevalence social disadvantage and census region hiv prevalence in a geographic area is the key epidemiological factor linked to the number of new cases in that area 24 we used countylevel hiv prevalence rates in 2015 to account for the existing patterns of hiv infection counties with suppressed data owing to low case counts were assigned case counts of 6 which represented the midpoint between the lowest possible suppressed value of 1 and the highest possible suppressed value of 11 studies have also shown that socioeconomic factors measured at the citywide level are the key drivers of new hiv infections 25 to capture the combined effect of multiple dimensions of socioeconomic disadvantage we calculated the social disadvantage index at the county level for the counties in our study 26 this index was calculated by summing the zscores for the percentage of the population living in poverty the percentage of the population with a high school degree or equivalent the median household income and the percentage of the population lacking health insurance these measures were obtained from the us census bureau small area income and poverty estimates and the american community survey 27 negative weights were applied to high school education and median income yielding an index that reflected greater social disadvantage for high values of the index and lesser social disadvantage for low values of the index census region was included to account for the regional variations in the hiv epidemic the four regions that is northeast south midwest and west regions of the united states were treated as the control variables in the models statistical analysis general sexrelated tweets were given sample weights of 625 for all the analyses to reflect the random samplings performed to reduce the data for coding we used the wilcoxon rank sum test with continuity correction for large samples to compare county tweet outputs based on the message source we used negative binomial regression to estimate the effects of twitter activity on hiv incidence at the county level our outcome of interest for this analysis was the rate of new diagnoses of hiv infections per capita at the county level to model this rate variable we included an offset term for the county population in 2017 in our regression analysis 28 negative binomial regression was chosen because our county outcome variables showed significant overdispersion from the poisson distribution unadjusted models were run first for each of the 6 twitter variables and the 3 control variables separate multivariate models were run for each of the twitter variables thereby adjusting for all the control variables variance inflation factors were examined for all final models and none showed evidence of multicollinearity analyses were performed in r351 29 using the mass package 30 glmnb function for negative binomial regression results descriptive and geospatial data our data included 2517 tweets that were identified as potentially relevant to hiv risk and prevention tags and these tweets originated in 109 counties across the united states of these 940 were general sexrelated tweets and were given a sample weight to reflect our random sampling procedure each tweet in our data set represents 100 tweets in the real world as our data was drawn from 1 of publicly available tweets however we have reported all our results in units of true tweets which were calculated by multiplying our results by 100 in 2016 321 hivspecific tweets on an average originated from individuals in each county counties had an average of 143 preventionrelated and 118 riskrelated tweets from individuals an average of 944 hivspecific tweets 843 preventionrelated tweets and 31 riskrelated tweets originating from institutions were sourced to each county institutions tweeted significantly more hivrelated and preventionrelated messages and significantly less riskrelated messages as compared to individuals within counties that had at least one potentially relevant tweet the median number of new hiv cases diagnosed in 2017 was 70 per county hiv prevalence in these counties ranged from 602 to 2590 per 100000 residents with a median prevalence rate of 306 per 100000 residents the social disadvantage index ranged from 652 to 753 the crude incidence rate ratios for each variable of interest of hiv incidence in 2017 were calculated using negative binomial regression with an offset for the county population hiv prevalence in 2017 was positively associated with hiv prevalence in 2015 and social disadvantage index in 2015 compared to that in the midwest region significantly higher hiv incidence was observed in the northeast and south regions of the united states we did not observe a significant difference in the counties in the west region of the united states the large number of prevention tweets from individuals in 2016 was significantly associated with the high incidence of hiv in the following year no other significant bivariate associations were found between hivrelated tweets and hiv incidence for combinations of tweet category and user type multivariate analyses multivariate models were used to test the adjusted effects for each of the 3 categories of tweets for individuals and institutions separately on hiv incidence in the following year these models are summarized in tables 3 and4 in all 6 models hiv prevalence in 2017 was positively associated with hiv prevalence in 2015 and social disadvantage index additionally all 6 models showed a significant difference in hiv incidence between the south and midwest regions only one model model 1 showed statistically significant effect for a tweet variable on hiv incidence in model 1 hivspecific tweets originating from individuals were negatively associated with hiv incidence at the county level in the following year after adjusting for region hiv prevalence and social disadvantage index each additional 100 hivspecific tweets per capita that originated from an individual in a given county was associated with a 3 decrease in the incidence rate of hiv in the following year after adjusting for covariates discussion principal findings in this study we analyzed the association between geolocated hivrelated tweets within the united states and the future incidence of hiv infection hivspecific tweets were more likely to emerge in those locations in the united states that had a high incidence of hiv the number of hivspecific tweets made by institutionassociated accounts was higher than that of individual tweets interestingly riskrelated information in institutionassociated tweets was lesser than that in tweets made by individual users however we did not observe significant associations between the number of hivspecific tweets made by institutions and countylevel hiv incidence in contrast increased numbers of hivspecific tweets made by individual users were significantly associated with the decreased number of hiv cases in the following year at the county level even when controlling for the geographic location these findings suggest that the source of the tweet plays an important role with individuals tweeting less about prevention and these individual tweets showed a strong association with the future outcomes of hiv infections geolocated conversations regarding hiv infections were negatively associated with countylevel hiv incidence these findings suggest that locations with few hivrelated twitter posts and conversations by individuals may indicate those that require targeted interventions thus counties with high incidence of hiv infections and few tweets may indicate an opportunity for increased investigation and potential intervention there are several possible reasons for our observation of low incidence of hiv infections in counties with large numbers of hivrelated tweets in the previous year increased numbers of hivrelated tweets at the county level could indicate increased community involvement policy initiatives and resource utilization in a given county 31 additionally increased numbers of hivrelated tweets by individuals could reflect increased activities in addressing various determinants of hiv risks including limited institutional support and reduced access to health care 32 although studies have sought to incorporate realtime analysis of twitter data in association with localized hiv incidence uptodate hiv epidemiological data is limited or inaccessible to researchers it is critical that public health professionals and computer scientists collaborate to develop novel approaches in analyzing twitter data in accordance with the available hiv epidemiological data our findings corroborate those of ireland et al 15 but they are in contrast to those reported by young et al 8 who found a positive association between hivrelated tweets and hiv prevalence although our study was similar in concept to that conducted by young et al 8 we used a more specific definition of hivrelated tweets by excluding keywords that were less sensitive in our training sample and including a variety of slang terms that were compiled by our young researchers moreover our study may have some slight differences from that of young et al 8 because of the time period in our studywe may have identified a more recent phenomena in the prevalence of hiv infections two previous studies 1415 analyzed the association between the hivrelated tweets and the corresponding epidemiological data in the same time period as considered in our study whereas young et al 8 analyzed the twitter data with the epidemiological data of the previous year the analyses in this study mirror those reported by young et al 8 because we also analyzed the epidemiological data from the year after obtaining our specified frame of tweets in 2016 our findings suggest that discourses on hiv and risky sexual behavior on twitter may serve as a signal of sexual health outcomes at the aggregate level however the low effect size and nonsignificant results of some of the models make it difficult to state this fact conclusively it is clear that hivrelated discourse is geographically concentrated and in coordination with epidemiological surveillance efforts it may be used to inform intervention efforts despite the relative rarity of direct discussion of hiv on twitter this social media platform is still an important medium for conversations regarding hiv and health behaviors given its wide user base twitter can serve as a platform for discussing useful hiv prevention strategies and such platforms deserve further investment as tools to end the hiv epidemic this study has several strengths our analysis combined nlp and manual coding thereby allowing for coding of a large number of tweets for indepth meaning while preserving context our use of geolocated tweets allowed for locationbased analysis with epidemiological and census data these aspects of our study allowed for contextualized analysis of twitter data which may be useful for targeted interventions across the united states limitations this study has several limitations first we did not evaluate model significance by using multiple correction comparisons our study only used a set of geolocated tweets from 2016 which greatly reduced the available sample this analysis included 108 of all the counties and there may have been different twitter discourses in other regions that were not included in this analysis it is possible that tweets that were not geolocated in that year could have revealed additional information about the nature of hivspecific tweets relative to hiv incidence second we excluded spanish tweets which limited our ability to capture the webbased discourse among latino men third since we focused on deidentified twitter data our study does not contain information on individual characteristics or behaviors conclusion with the increase of public discourse through twitter public health efforts leveraging this social medium are needed social media platforms such as twitter offer an opportunity for health professionals to monitor population health and promote hiv disease prevention we observed a negative association between hivspecific tweets made by individual users and hiv incidence in the following calendar year at the county level our study underscores the importance of social media as a crucial aspect in the lives of individuals as these discourses might unearth the youths knowledge attitudes and beliefs related to hiv public health efforts seeking to use social media as a tool for hiv surveillance and intervention are warranted conflicts of interest none declared abbreviations irr incidence rate ratio nlp natural language processing prep preexposure prophylaxis sti sexually transmitted infection edited by g eysenbach submitted 251119 peerreviewed

background adolescents and young adults in the age range of 1324 years are at the highest risk of developing hiv infections as social media platforms are extremely popular among youths researchers can utilize these platforms to curb the hiv epidemic by investigating the associations between the discourses on hiv infections and the epidemiological data of hiv infectionsthe goal of this study was to examine how twitter activity among young men is related to the incidence of hiv infection in the populationwe used integrated humancomputer techniques to characterize the hivrelated tweets by male adolescents and young male adults age range 1324 years we identified tweets related to hiv risk and prevention by using natural language processing nlp our nlp algorithm identified 891 22432517 relevant tweets which were manually coded by expert coders we coded 1577 hivprevention tweets and 175 9405372 of general sexrelated tweets including emojis gifs and images and we achieved reliability with intraclass correlation at 080 or higher on key constructs bivariate and multivariate analyses were performed to identify the spatial patterns in posting hivrelated tweets as well as the relationships between the tweets and local hiv infection rateswe analyzed 2517 tweets that were identified as relevant to hiv risk and prevention tags these tweets were geolocated in 109 counties throughout the united states after adjusting for region hiv prevalence and social disadvantage index our findings indicated that every 100tweet increase in hivspecific tweets per capita from noninstitutional accounts was associated with a multiplicative effect of 097 95 ci 094100 p04 on the incidence of hiv infections in the following year in a given countytwitter may serve as a proxy of public behavior related to hiv infections and the association between the number of hivrelated tweets and hiv infection rates further supports the use of social media for hiv disease prevention

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introduction the past two decades have witnessed a rapid and relentless increase in the use of digital technologies these innovations in digital information and communication technologies have the potential to have a positive impact on health and to be democratic in the way that they bring innovation and opportunities to people digital technologies are becoming increasingly important as ways to gain access to most of the important social determinants of health including employment housing education direct health information and access and social networks yet little is known about the ways in which these technologies will impact on health equity this paper will explore how digital technologies are an increasingly important determinant of health and argue that health promoters need to develop an understanding of how they interact with and reinforce other social determinants of health and how they have the potential to increase existing health inequities the digital revolution and its differential impact the development and diffusion of digital icts are having a profound effect on modern life and are viewed as having the potential to either health promotion internationalvol 29 no 2 doi101093heaprodas062 the author published by oxford university press all rights reserved for permissions please email advance access published 9 november 2012 alleviate or exacerbate existing inequalities being able to use digital information and communication networks is increasingly important for people to gain full citizen participation in economic social educational political and cultural life this is particularly so as the private sector and government are relying more and more on ictmediated provision of services support and information health services around the world are also increasing their use of digital communication intending that for service users this will improve access convenience timeliness and control and for providers will save costs and resources this revolution in communication technology has happened rapidly over the past two decades and has profound implications for our lives in terms of health these changes have the potential to be a force for more equitable population health but only if the implementation and impacts of using new technologies are assessed for likely impacts on health status the impact of technologies on equity have been noted with parsons and hick talking of the digital divide discussing the impact of this divide and the need to move to notions of digital inclusion furthermore helsper et al have shown that across most of europe and the major englishspeaking countries the uptake of digital technologies mirrors existing social inequalities as indicated by the gini coefficient van dijk has also argued that the distance between the information elite and the unconnected or excluded is widening leading to rising levels of social and communication inequality nevertheless mclaren and zappala noted that little is known about the factors associated with access and use of ict among different socioeconomic groups in australia concern has been expressed that as moreadvantaged groups continue to have better digital access the lessadvantaged will have restricted access to a range of opportunities made possible by icts and that this would eventually lead to a steeper social and health gradient indeed even when disadvantaged people do use the internet they are often less likely to engage with activities from which they would benefit most such as for economic activities and services health literacy and basic literacy in the digital era it is argued that healthcare communication in an increasingly digital world demands more health literacy from consumers particularly when fundamental literacy also continues to be a critical yet often ignored social determinant of health inequities in both developed and developing countries health literacy constitutes the knowledge and skills which enable a person to navigate the health continuum as a patient in the healthcare setting as a person at risk of disease in the disease prevention system and as a citizen in relation to health promotion efforts us national data clearly links health literacy to fundamental literacy which is a key factor in health access for anyone with an education below high school level in australia 7 million people aged 1574 have scores at the lowest 2 levels of proficiency in general reading while for health literacy approximately 9 million australians attained scores at only level 1 or 2 and only 900 000 were at level 45 a dutch study tested a randomly selected group of the dutch population in terms of their ability to use the internet for ehealth purposes according to four operational skills from basic to strategic the study found that educational attainment was the best predictor of being able to use the internet strategically to gain benefits this study suggests that it is important to know not just whether people have access to the internet but also what use they make of it and the extent to which they benefit from it exclusionary processes much of the research has been concerned with technical access issues and has not explored social cultural and motivational issues some people are even becoming digital dropouts or persistent exusers of icts suggesting that exclusionary processes are at work and that along with other forms of exclusion digital exclusion is becoming another way in which inequities are perpetuated there have also been calls to research the relevance appropriateness and awareness of certain icts and their potential benefits differing levels of adoption and the role of social networks in relation to ict access and use kvasny and keil 2006 australian communications and media authority 2007 gilmour 2007gilbert et al 2008 castells notion of power in the global network society sees actors and organizations who are inside network structures holding power over those outside these structures and setting up rules which exclude them the increasing demands being placed on consumers to communicate through digital channels could be interpreted as one such exclusionary rule established by health organizations digital access and use in australia home internet access is associated with more complex activities and freedom of use than community access such that it is now seen by researchers as an indicator of highquality access and important for increasing digital engagement australian data for 20102011 shows that 79 of australian households overall have home internet previously we reviewed the evidence on the distribution of internet access in australia and concluded that the distribution suggests the existence of a digital gradient further australian data also indicate that the distribution of digital technology access is not evenly spread and that socioeconomic characteristics of households in particular continue to influence the rate of internet connectivity households still less likely to be connected are those with lower household incomes those without children under 15 years those outside of major metropolitan areas and those on low incomes among australians aged 15þ 22 of women and 19 of men did not use the internet anywhere in the previous 12 months the income gradient in digital access has continued and by 20102011 while over 90 of the top quintile had access only a little over 50 of the lowest quintile did and even among those with access the more disadvantaged groups report less frequent use other differences include 86 of remote indigenous australians being without home internet compared with only 37 of the remote nonindigenous population data also show that even when people have home internet there are still barriers to actually using it for older australians while 49 of women have home internet only 37 used it in the last 12 months for men these figures are 58 and 47 respectively comparative data for australians with a disability show 61 of women with home internet but only 52 using it and 64 of men with home internet but only 55 using it all these data linked to socioeconomic inequalities which underpin health suggest that digital technologies have the potential to reinforce existing health inequities bourdieu and digital icts forms of capital and the digital world as a field the existence of a range of social and economic inequities underpins health inequities bourdieu has explained the existence of inequities through reference to the ways in which class reproduces itself through societal mechanisms that either enhance or restrict access to social economic and cultural capital competition for these forms of capital and the interactions between them shape the distribution of power in a society in this paper we use bourdieus concepts of different capitals to examine the ways in which they affect access and use of digital icts and how restricted access in turn limits the vicious cycles 351 potential for capital accumulation bourdieu also described the concept of fields as the social and institutional arenas where individuals compete for the distribution of different kinds of capital fields reflect power hierarchies such that individuals experience power differently depending on the particular field we conceptualize the digital world as one societal field in which the struggle for resources is conducted and on which power is unevenly distributed this paper uses bourdieus ideas to explore the ways in which digital icts operate to both reflect and exacerbate inequities in access to the social determinants of health it considers the factors that affect access to digital icts and the results of experiencing total or partial digital exclusion the paper concludes with a discussion of the implications of our findings for health promotion practice methods focus groups six focus group discussions were conducted between august and november 2008 in five outersuburban and one innercity area of adelaide the capital city of south australia and home to 73 of the states 16 million population focus groups allow for an initial grounded exploration of issues through interactive discussion and are particularly valuable for researching with people from lower socioeconomic backgrounds or vulnerable groups because they give voice to the research participants and allow them to define what is relevant and important to understand their experiences people were recruited to the focus groups with assistance from individuals working in local communities and service organizations known to the researchers the settings and providers were located in areas identified by glover et al and abs as lower socioeconomic status according to education level income and occupation group recruitment was focused in the 25 55 year age rangethe main family formation and working age groupsince there is already some australian focus on researching digital technologies with disadvantaged youth and with older culturally diverse communities the six focus groups with a total of 55 participants were the following † 1 womenspecific community support group † 1 menspecific community support group † 1 workunemployment support group † 1 group living in community rental housing provided at an affordable price to people on low incomes andor at risk of homelessness † 1 aboriginal group † 1 africanborn recentrefugee group for the refugee group who were not proficient in english the researchers questions and participants responses in english were interpreted into the groups native language by an accredited and experienced interpreter who was known and trusted by the group and participants native language responses were interpreted back into english focus group discussions were tape recorded verbatim and transcriptions were analysed for content and themes each participant was thanked for their participation with a lunch and an au 30 shopping voucher the research project was approved by the social and behavioural research ethics committee at flinders university the focus group question guide was developed from a literature review questions from previous digital surveys and discussion with the research reference group questions included the following what types of icts are you using and whywhy not how did you learn to use those icts what barriers do you see to using icts and how could these be overcome are there downsides to using icts do your social networks mediate accessuse or motivate you to use icts and what is the impact of usingnot using icts on opportunities for employment housing education convenience and creating maintaining social networks however as is common with indepth interviewing as other issues arose spontaneously they were probed and followed up by ln and kp one such issue was the way in which the existing social cultural and economic capital which individuals had access to shaped the degree to which they were able to access and use icts transcripts were analysed according to established methods to provide a descriptive account ln and kb conducted all groups which allowed continual data immersion they then used a constant comparative iterative method to analyse two transcripts individually allocated text to a priori and emergent codes and compared and discussed interpretations to derive a coding framework this framework was applied to the other transcripts and new emergent codes were discussed and added as analysis proceeded with subsequent groups new questions were incorporated into the schedule to further explore emerging ideas the final framework consisted of dominant categories in this paper we examine the data relating to digital exclusion and the impact on the social determinants of health including the ways that different capitals impact on access and use of digital icts and the ways in which access to and use of digital icts shapes peoples opportunities in other areas of their life the analysis conducted for this paper involved fb reviewing the existing codes and interpreting them in light of bourdieus theories thus we drew out of the transcripts the themes that related to the ways in which our respondents existing capitals shaped their ability to access and use ict and then analysed the ways in which the digital world has become a social field in which existing inequities are played out and reproduced findings our findings show that people from low socioeconomic groups are restricted in the ways that they can access and use digital icts and that this limited access and use can in turn affect their access to a range of social determinants of health restriction on access and use table 1 summarizes the factors that we found limited peoples digital ict access and use this analysis shows that lower levels of social economic and cultural capital all work to make access and use of digital technologies more difficult thus people cannot always afford to purchase the new technologies report that their limited educational opportunities means that using the technologies can be difficult and that they do not necessarily have the social connections to support their use these data show how limited income restricts peoples access to digital icts as expenditure is seen as a luxury or extravagance and is one item amongst a range of facilities that people on lower incomes are forced to choose between similarly the lifetime accumulation of educational opportunities and related levels of literacy and confidence in learning new skills translates into the ability to access use and benefit from digital icts the quotations in table 1 in particular highlight the role of fundamental literacy especially reading skills that are likely to result from lack of educational opportunities this restricts even native english speakers from using the internet because much of it is in written form and textdense these issues are then compounded in a mainstream english culture for those whose first language is not english many people also gain their skills in using new technologies through their employment such that those who are not in the workforce as well as often having lower incomes and poorer educational history are also lacking onthejob ict training that many others gain as a side benefit of their employment thus a life in which access to cultural and economic capital has been limited means that access and use of digital icts is more difficult in the present exclusion from digital icts has therefore become one of the many ways in which people who are already disadvantaged potentially suffer a further level of disadvantage overcoming barriers to digital ict access and use nevertheless we found that access to and use of digital icts could be aided by people having social connections as these examples suggest i got into the course im doing at the moment because someone from here researched on the web for me she printed out several web pages so when i go down to my sisters place i use her computer like she does all my banking online and we do everything from bill paying to basically just doing everything otherwise i have to drive to six or seven different places paying cash for it i know enough people i could ring up and say hey on the weekend can i come over and can you turn your computer on and do something for me i taught my nana and aunties everything they need to know about their mobiles it took them a few months though each of these examples demonstrates that social capital can contribute to reducing digital exclusion but that peoples exclusion is intensified if they do not have networks which include people with the skills and time to pass on digital skills others spoke of the way in which having employment can provide opportunities to learn skills for digital ict use this illustrates the ways in which the possession of one form of capital can then lead to the acquisition of digital capital this transference between different types of capital was frequently described by participants demonstrating how exclusionary processes may be at work in the digital field digital capital shapes access to other social determinants of health we further found that once people are excluded from digital ict access and use then this has implications for opportunities in other social determinants of health looking for employment is also made more difficult and not having the skills to use technologies also inhibits employment opportunities digital exclusion is also seen as having social impacts in that our focus group participants noted that access to digital icts is increasingly important in making and maintaining social contacts many of our participants also reported that inadequate access to digital icts was in and of itself socially excluding and recounted the ways in which this happened to them discussion a model of the health effects of inadequate digital access and use a digital vicious cycle our findings have painted a picture of the ways in which people who are already disadvantaged in terms of their access to economic social and cultural capital are further excluded from access to social determinants of health and wellbeing in the digital field because they have insufficient existing capitals to help them accrue digital capital hence they are in danger of being caught in a vicious cycle of digital exclusion thus to take the example of education if people have had inadequate educational opportunities in their life then this may operate as a barrier to them accessing and feeling confident using digital technologies and also means that they are as a consequent of this lack of access more likely to be excluded from educational opportunities as these increasing rely on digital capital the educational opportunities to acquire fundamental literacy also shape health literacy which therefore in turn affects peoples ability to improve their health status and health outcomes this disadvantage is compounded because digital literacy is increasingly a prerequisite for health service delivery and access to health information as one participant commented if you cant damn well read how are you meant to access the internet in the first place importantly helsper and galacz point out that if it is just access that is the problem then this will disappear when the current generation of elderly nonusers passes away and the tech savvy digital generation grows up in other words the digital exclusion shown in figures 1 and2 will simply disappear over time however in bourdieus terms the low levels of capital which may exist for example among youth from disadvantaged backgrounds means that when it comes to socioeconomically disadvantaged youth playing on the field of digital icts as they grow up they will still experience disadvantage low literacy levels and lack the power and resources to benefit from this field due to the process of digital exclusion which we show in figure 2 and particularly as fundamental literacy health literacy and digital literacy overlap requiring increasingly complex or new skills and cognition for sophisticated use and constant financial expenditure to keep up in contrast to tondeur et al who see digital capital as just a new aspect of cultural capital we found that social cultural and economic capital are all transferable to and impact upon digital capital that is in gaining access to and using digital icts for their benefit those lacking access to these capitals are also either absolutely or relatively excluded from the technologies and benefits they bestow implications for health promotion practice and policy working for health equity is an important part of good health promotion practice consequently health promoters need to consider the ways in vicious cycles 355 which the digital ict vicious cycle we have described can be interrupted so that access to the digital field is more inclusive considering what can be done about each form of capital is a helpful starting point in terms of changing economic capital reducing the cost of digital hardware and broadband access for people on low incomes is one possibility free access to the internet can also be provided in public facilities such as libraries community health centres or primary healthcare facilities although our previous research showed that people find this access less satisfactory than 24 h home access and 10 of australians use the internet in public libraries or government shopfronts such low levels of use might be increased if assistance were available to support users as they needed it which would at the same time serve as a way to upskill people on an issue of interest to them such strategies are being used as part of the australian implementation of an improved national broadband network increasing cultural capital requires investment in education and recognition that this is particularly important for people on low incomes those who do not speak english and those who suffer other adverse conditions in their life such as inadequate accommodation or unemployment helsper finds that in the uk gaps based on education and employment persist regardless of age or other characteristics such that a digital underclass is emerging who will miss out as government services become digital by default people may be more encouraged to learn to use icts if the opportunity to increase specific skills were offered in entry level workshops directly relevant to these specific skills a communitywide programme to encourage adult peerlearning about digital technologies in community locations which people from low socioeconomic backgrounds are familiar with and feel comfortable with could assist with increasing peoples competence and confidence in using digital icts some countries already have national programmes to support disadvantaged individuals to do this such as the network of 3800 uk online centres focused in disadvantaged neighbourhoods and canadas community access program such approaches would also work to increase peoples access to social capital and the benefits it can bring health promoters themselves also need to ensure that they do not assume all people have equal access to and ability to use digital icts when implementing online forms of communication or in the provision of online health information or selfmanagement in particular health promoters need to understand the barriers posed by the interaction of digital literacy with health literacy and fundamental literacy and to consider this when deciding whether to direct patients to internetbased information or selfmanagement this may mean continuing with appropriate resources in traditional and in languages other than english and working with clients to ascertain the communication methods for which they do have the necessary capitals it also means that services should offer more than digital options as only providing a website without phone or facetoface options in itself may alienate some potential clients our research supports other recommendations that regardless of whether health communication is in digital or traditional formats consideration must be given to whether this matches the users skills abilities and level of knowledge in light of the various literacy barriers related to digital communication our vicious cycles 357 research suggests it is also essential to consider the continuing role of verbal communication this is particularly essential for those groups who prefer nonwritten formats providing offline phone counseling alongside online counseling is one example of a diversified strategy and could be effective with less advantaged groups if the health service pays for the cost of the phone call however it can be more expensive to call counseling numbers from a mobile phone than a landline phone and disadvantaged groups are significantly overrepresented in the mobileonly population written communication could be mediated by a health professional who might for example sit with a client to find and interpret relevant internet information rather than directing a patient to do this alone when they do not have the necessary capitals for successful access since our respondents cited family and friends as playing a key role in internet access the provision of computer and internet hardware in community or health settings may be more useful to consumers if it were supported by an internet mediator or healthpromoting buddy who could assist with digital and fundamental literacy issues for internet access as well as providing health literacy support a us hospital serving vulnerable populations uses an imagebased touchscreen with audio options which patients can use to learn basic health information while waiting for appointments all of which negate the need for computer or internet navigation skills the assumption that all groups have equal access to digital icts should be questioned in all settings and strategies and policies developed to address the needs of those who miss out or who need additional assistance in using and benefiting from digital icts in terms of any or all of the three literacies we have identified finally from a whole of population access view point targets for achieving coverage of digital icts should reflect the complexities of the digital gradient simple population figures should be changed to address equity with the constant changes in technology type and complexity it is necessary to continue questioning differences in the quality of use and whether all people have the resources skills and motivation to make beneficial use of any technology further research should also be conducted to identify how moves to introduce or expand digital communication in health services will impact on equity of access and use for consumers health promoters can play a key role in lobbying for the collection of data to identify equity targets and advocating about the importance of digital inclusion to health and wellbeing including in terms of government wide estrategies and approaches conclusion access to digital icts is a crucial social determinant of health in the twentyfirst century and is not just a matter of technical access but is determined by peoples history of and current access to social cultural and economic capital it is vital that health promoters understand and account for the complex interaction between digital literacy health literacy and fundamental literacy exclusion from digital capital creates a vicious cycle of disadvantage and health promotion has a role to play in working to interrupt this cycle and to promote and advocate for processes that encourage digital inclusion in order to contribute to the goal of greater health equity

digital technologies are increasingly important as ways to gain access to most of the important social determinants of health including employment housing education and social networks however little is known about the impact of the new technologies on opportunities for health and wellbeing this paper reports on a focus group study of the impact of these technologies on people from low socioeconomic backgrounds we use bourdieus theories of social inequities and the ways in which social cultural and economic capitals interact to reinforce and reproduce inequities to examine the ways in which digital technologies are contributing to these processes six focus group discussions with 55 people were held to examine their access to and views about using digital technologies these data are analysed in light of bourdieus theory to determine how peoples existing capitals shape their access to and use of digital technologies and what the implications of exclusion from the technologies are likely to be for the social determinants of health the paper concludes that some people are being caught in a vicious cycle whereby lack of digital access or the inability to make beneficial use reinforces and amplifies existing disadvantage including low levels of reading and writing literacy the paper concludes with a consideration of actions health promoters could take to interrupt this cycle and so contribute to reducing health inequities

19042_0

background the 2019 novel coronavirus called sarscov2 referred to as covid19 is a new strain of coronavirus first reported from wuhan a city in china in december 2019 1 covid19 spreads by humantohuman transmission through respiratory droplets of an infected person 2 public health experts have recommended hand hygiene practices use of masks respiratory etiquette and physicaldistancing as key measures for controlling the spread of covid19 3 the pandemic has affected all aspects of peoples lives caused financial and social hardships and impacted health and quality of life 4 changes in lifestyle due to prolonged lockdowns have resulted in increased stress weight gain reduced physical activity and decrease in sleep quantity and quality 5 it has disrupted the global economy 6 affecting the marginalized and pushing them to extreme poverty 7 the pandemic has also generated a lot of media attention both print and electronic an adverse effect of this infodemic has been the widespread circulation of misinformation especially in the social media 89 in a systematic review of covid19related publications in social media during the first phase of the pandemic up to 29 of the social media posts related to covid19 were classified as misinformation 10 during infectious disease outbreaks misinformation can cause fear stigma and panic among the public 811 from the severe acute respiratory syndrome experience it was learnt that public health education and communication helps in mitigating fear and stigma of the disease 11 those with better knowledge are less anxious less likely to stigmatize others and therefore positively impact the ability to control disease spread understanding knowledge perceptions and practices of individuals and communities can help in developing targeted information education and communication campaigns and other nonpharmacological control efforts this communitybased crosssectional study aimed to assess the knowledge perceptions and practice toward hand hygiene respiratory etiquette and the need for a holistic approach toward pandemic control lessons… community quarantine among rural and urban households of meghalaya during the early phase of the covid19 pandemic at the time of total lockdown in india additionally it assessed the healthseeking behavior stigma fear and discrimination related to covid19 among the residents although studies exploring awareness 12 13 14 15 16 17 18 19 20 21 22 23 healthseeking behavior 24 25 26 and stigma related to covid19 2728 have been reported from different parts of india to the best of our knowledge this is the first communitybased study to have been conducted in the northeast region of india which has distinct cultural beliefs and practices moreover the previously reported studies were either conducted online 1220 23 2528 or telephonically 2124 or within specific population subgroups 13172022 24 25 26 27 28 which may result in biased inferences due to lack of generalizability 2930 a comprehensive understanding of the community perception and healthseeking behavior can enable policy makers to plan mitigation and control measures to effectively tackle future pandemics methods study area and population meghalaya is a hilly state in the ner of india with a population of around 3 million about 75 are literate 31 the population is largely indigenous with majority belonging to three main tribes khasi jaintia and garo 32 meghalaya shares international boundaries with bangladesh in the south and west and is bordered by assam in the north and east 33 to minimize the impact of covid19 the government of meghalaya adopted a combination of containment and mitigation measures such as imposing travel restrictions curbing commercial activities registering and testing entrants and undertaking extensive iec activities encouraging people to adopt hand hygiene respiratory etiquette social distancing and homeinstitutional quarantine the iec materials in english as well as in the local language were disseminated through conventional and social media and daily announcements were carried out by the dorbar shnongs to emphasize the collective responsibility of communities in preventing spread of covid19 we conducted a communitybased crosssectional survey in 14 localities of three districts in meghalaya east khasi hills west jaintia hills and ribhoi within large urban villages localities have several smaller agglomerations known as dongs between may and june 2020 the research team approached the permanent residents of these dongs for participation respondents were adult members aged 1860 years households with one or more members under quarantine were excluded sampling technique we employed a multistage sampling technique and randomly selected 30 dongs using computer generated random numbers from 14 localities to ensure a representative sample we subdivided each large dong into three sections with the number of sampled households divided equally the participating households were selected using a systematic random sampling technique wherein we randomly selected the first household from among the houses in the leftmost corner of the area thereafter every fifth household toward the right was approached until the targeted sample size was achieved in the event of a household refusing to participate or a household member being under quarantineisolation we approached the adjacent household for participation we recruited only one eligible participant per household for the study to obtain equal representation of male and female participants we attempted to select alternate female and male respondents ie if a female participant was recruited from a household a male participant from the next household was approached for participation if the participant refused or was not available we recruited another eligible participant from that household data collection procedure we developed a semistructured questionnaire to capture demographic data of the survey participants knowledge of clinical symptoms transmission and prevention of covid19 healthcareseeking behavior during the pandemic changes in hand hygiene and respiratory etiquette and perceived anxiety fear and discrimination related to covid19 we adapted the following instruments world health organization risk communication and community engagement action plan guidance covid19 preparedness and response 34 can we measure hivaidsrelated stigma and discriminationcurrent knowledge about quantifying stigma in developing countries 35 hivaids stigma and discrimination in developing countries 36 and fear of covid19 scale 37 we first developed the survey questionnaire in english and then translated to the local language it was piloted among family members of the data collectors for language and comprehension the households included in the pilot survey were excluded from the main study we standardized the data collection process through multiple virtual training sessions for data collectors using video conferencing facilities we conducted role plays during these sessions to ensure that the data collectors were wellversed with the questionnaire the consent process and followed the pandemic protocol we also conducted afterevent reflections after the second and fifth day of data collection during which the challenges faced during data collection were addressed statistical analysis we analyzed the data using stata 15 for windows statistical software for descriptive statistics we used mean and standard deviation or median and interquartile range for continuous variables and frequency counts and marginal percentages for categorical variables we calculated the 95 confidence intervals using the taylor linearized method that accounts for the clustered data structure 38 with dongs assigned as the primary sampling units to assess statistically significant differences between practices before and during covid19 we used the mcnemars test 39 to evaluate imbalance in discordant pairs for nominal data a p value 005 was suggestive of significant difference in the marginal proportions ethical consideration we obtained ethical clearance for conducting the study from the university research ethics committee martin luther christian university meghalaya we also obtained permission from the department of health and family welfare government of meghalaya we consulted the headman of each locality and obtained permission from him prior to the survey the data collectors obtained verbal consent from all participants to ensure their voluntary participation interviews were conducted by the data collectors at the participants home and an identity code assigned to each participant to maintain confidentiality results demographics a total of 416 participants responded to the survey majority of the participants were females belonging to khasi or jaintia tribes around threefourth were christians almost half of the participants had graduatelevel education the demographic details of participants are presented in table 1 knowledge on covid19 preventive measures factors of transmission most of the participants were aware of the important signs and symptoms of covid19 such as fever difficulty in breathing and coughing almost all participants could correctly identify the modes of transmission of sarscov2 for instance 95 and 96 participants respectively attributed shaking hands with an infected person and infected droplets as potential modes of transmission participants were also aware of the best practices for preventing the spread of sarscov2 such as washing hands with soap and water for at least 20 s wearing a face mask and avoiding contact with sick people healthseeking behavior stigma perceived discrimination and fearanxiety related to covid19 approximately 16 of participants reported delaying a hospital visit for treatment of routine illnesses in them or their family members during the covid19 pandemic close to onetenth of the 148 the participants requiring medication reported inability to procure their routine medicines during the pandemic almost all participants agreed that people should inform the health authorities should someone develop covid19 symptoms more than onethird of blamed people traveling from outside of the state for spreading sarscov2 more than onefourth of participants expressed fear of losing their life from contracting the virus 17 mentioned that they were unable to sleep at night due to worry about contracting covid19 close to half expressed anguish and nervousness while watching news and stories about covid19 on conventional and social media discussion in this study participants had adequate understanding of the virus and the disease including knowledge about the common signs and symptoms mode of transmission and measures of prevention during the early phase of the pandemic we also noted a positive behavior change among the participants most participants reported preventive measures illustrated by an increased frequency of handwashing avoiding of crowded places and avoiding spitting in public places during the pandemic importantly we also noted that participants reported fear of the disease resulting loss of sleep and nervousness and perceived discrimination and stigma toward travelers and covid19 positive individuals the findings of this study are consistent with observations in other settings where participants were found to be aware about the clinical symptoms of covid19 its transmission and prevention the highrisk groups and the need for quarantine 22 40 41 42 this demonstrates a high level of awareness about the pandemic in the general population even during the initial phase of the pandemic possibly due to the extensive iec efforts by different governmental and nongovernmental agencies the importance of having correct knowledge to enable individuals to make informed decisions about change in behavior to ensure better compliance with preventive measures has been emphasized repeatedly 43 despite adequate knowledge about covid19 some participants reported delay in healthcare seeking for routine illnesses during the pandemic the delay in healthcare seeking 44 45 46 47 including the use of emergency services 4849 and an increase in selfmedication 50 during the pandemic have been reported earlier this may have resulted in an increase in mortality from noncovid19 illnesses such as cardiovascular diseases and neoplasms 51 a major reason for this is the fear of contracting covid19 at healthcare facilities 4546 taken together the findings highlight the importance of allaying public fear and perception and encouraging people to avail routine healthcare services irrespective of the covid19 status of the patient per the who efforts to address delay in healthcare seeking for noncovid19 illnesses must also be part of the covid19 response 52 public health behavior change is challenging 5354 and requires integration of insights from several psychological and sociological theories 54 the aim of disseminating information is to translate it into practice resulting in a positive behavior change in this study we noted a significant change in behavior during the pandemic a large proportion of participants reported practicing several hygienic practices such as frequent handwashing or coughingsneezing into the sleeves which were not commonly carried out before the pandemic an increase in compliance to the preventive measures during the pandemic has been reported by participants from other studies 40415556 although how long such positive behaviors are maintained and the possible techniques for reinforcement remains uncertain future studies may consider evaluating longterm behavior change resulting from pandemics such as covid19 to identify cues for motivating participants to maintain positive behaviors 57 in this study we noted that some participants perceived discrimination toward individuals with covid19 with the feeling that covid19 patients faced rejection and loss of respect in the community additionally some participants stigmatized returnees from other states for spreading the disease incidents of social stigmatization have been reported from other parts of india wherein suspected or infected individuals their family members deceased individuals migrant workers or even healthcare providers were victimized 5859 such issues of stigmatization and discrimination should be tackled with equal importance as the prevention and treatment of covid19 60 the who has suggested that leaders should publicly condemn any act of stigmatization or discrimination and encourage those who follow the public health measures recommended from time to time furthermore iec activities that reduce discrimination and stigma should be promoted 61 we also noted that there is a marked fear toward covid19 with some participants reporting loss of sleep at night and almost half reporting nervousness and anxiety from media reports on covid19 common mental health issues reported among indians during the pandemic include stress anxiety depression insomnia denial anger and fear that oneself or a family member may get infected 62 sleep difficulties paranoia and distress from covid19related information in social media have also been reported 23 taken together this highlights an increase in mental health issues during this pandemic the impact of the pandemic on mental health of people may last beyond the pandemic itself and hence should be addressed urgently 63 this study has several limitations firstly we cannot rule out a social desirability bias in some responses especially those related to change in handwashing and respiratory hygiene practices before and during covid19 secondly majority of the participants were from the urban areas which has a higher literacy rate than the rural areas 31 literate individuals are more likely to be better informed about covid19 thereby restricting the generalizability of the findings to urban settings and more educated population of meghalaya conclusion this study provides important insights on the knowledge perceptions handwashing and respiratory hygiene practices healthcareseeking behavior stigma fear and discrimination related to covid19 in a northeastern state of india during the early phase of the pandemic despite better knowledge about covid19 and its prevention a sizeable proportion of the participants reported fear stigma and discrimination toward covid19 patients this highlights the need for a holistic approach that includes the social and mental health interventions in addition to the clinical and public health measures to effectively mitigate the overall impact of the pandemic

we conducted a communitybased crosssectional survey of 416 participants from meghalaya india to assess knowledge perceptions and practices toward recommended covid19 preventive measures and to explore healthseeking behavior and stigma during early phase of the pandemic most participants had knowledge of the signs and symptoms of covid19 94 and its spread 96 and reported positive behavior change such as handwashing ≥ 6 timesday 41 precovid19 vs 81 during covid19 p 0001 sneezing or coughing into sleeves 65 precovid19 vs 89 during covid19 p 0001 and staying home if having flulike symptoms 44 precovid19 vs 94 during covid19 p 0001 we found delayed healthcare seeking for noncovid19 illnesses 16 fear of losing life was reported by 26 participants as was discrimination toward migrant returnees with 35 blaming returnees for the spread of covid19 we highlight the need for a holistic approach toward pandemic control including social and mental health interventions in public health strategies

19043_0

background sociocultural diversity needs to be considered during the design of hivaids policies and programmes social attitudes and prejudices towards people living with hiv aids sexual taboos and gender inequality are some of the most important challenges for prevention and treatment of hivaids 1 2 3 4 5 6 despite an improved performance of health and community services people living with hiv aids continue to face persistent deeply rooted social and cultural barriers international donors public health experts programme planners and policy makers need to begin to recognize the need to take into account this sociocultural diversity in program planning hence it is essential to gather the scientific evidence generated so far on this topic much of this evidence has been generated from qualitative studies the most important and frequently reported sociocultural barriers in both low income and high income countries include fear of disclosure anticipation of stigma limited social support interpersonal violence and alcohol abuse 2 3 4 5 6 7 to better understand the distribution frequency and potential impact that these factors may have on the population quantitative epidemiological surveys should ideally incorporate similar questions it is currently unclear to what extent sociocultural determinants of access identified by qualitative studies are addressed in survey studies to our knowledge there is no systematic review of epidemiological literature available to clarify this question therefore this article seeks to answer three questions what sociocultural factors have been measured in epidemiologic studies to assess access to hivaids services what are the differences between factors measured in low and high income countries and what are the associations and effect sizes of these factors methods a systematic search of quantitative studies addressing factors that influence access to hiv testing uptake of antiretroviral therapy and adherence to antiretroviral regimens was performed in order to determine the differences between the factors studied in low and high income and test whether these differences were consistent with the findings of qualitative studies for each context we scrutinized studies from low and lowmiddle income countries and from uppermiddle and highincome countries as defined by the world bank classification 8 to facilitate the comparative analysis and the description of the results the countries belonging to these four income groups were reclassified into two broader categories low and high income countries the category lowincome countries included low income countries and lowmiddle income countries and the highincome category included uppermiddle and highincome countries search strategy the search was restricted to studies with sample population over 18 years old and in english french german spanish portuguese and italian no other limitations were applied the systematic search lasted one day with date 07 th october 2011 the search terms were hiv or aids voluntary counselling and testing haart or antiretroviral compliance or adherence factors or determinant or barriers and motivat or facilitat the search included cinahl embase csa databases ibss isi web of science jstor medline psyinfo and psyindex and the cochrane database of systematic reviews conference abstracts from the international aids society conferences web site were also searched we complemented the search by reviewing the bibliographies of key papers the detailed search strategy is available upon request inclusion and exclusion criteria to be eligible articles needed to report an original research study measure one of these three outcomes hiv testing initiation of art and adherence to antiretroviral therapy study associations with sociocultural factors target adult participants over 18 years old apply a survey methodology for data collection estimate risk effects as an outcome and control for confounding in the analysis studies that reported sociodemographic or socioeconomic factors but not any of the other categories of sociocultural variables were excluded study selection and quality appraisal the study selection followed a fourstep process title review abstract review full text review and quality appraisal first two of the authors independently reviewed all identified study titles duplicates and titles that did not meet the inclusion criteria were removed the same authors then independently assessed the abstracts and then the full papers of those abstracts that met the eligibility criteria finally a quality appraisal was done on all full texts using consolidated criteria of the strobe guidelines 9 strobe is a checklist of 22 items that must be addressed in the report of observational studies this list is not really a tool to assess the quality of observational research but provides valuable guidance on the quality of reporting the studies in addition a modified version of the newcastleottawa scale for observational studies was used to assess the methodological quality 10 nos is a tool to assess the quality of non randomized studies to be used in a systematic review each study is judged with a star system on three points the selection of the study groups the comparability of the groups and the ascertainment of the exposure or outcome in our review only studies in which five of nine items on the nos were deemed satisfactory and in which appropriate statistical analysis was conducted were considered to be of high methodological quality at each stage of the quality assessment the reviewers discussed together until a consensus on which studies to include was reached finally the reviewers manually searched the reference lists of the included articles for further key studies that could potentially be included in the analysis data extraction and classification the following data was extracted and summarized in evidence tables citation year of publication country study design and sampling characteristics of the study population community versus facility based sample outcomes and factors that facilitated andor hindered access to hiv care such as sociodemographic socioeconomic medical health system knowledge and beliefs risky health behaviours psychosocial stigma and discrimination family and interpersonal violence communication about hivaids community prevalence an overview of data extraction is provided in tables 1 and2 the data was extracted and reviewed in duplicate from identified studies common indicators were grouped into bigger categories in duplicate by independent reviewers disagreements in the categorization of the factors were discussed until consensus was reached countries of the study were classified as high or low income countries as defined by the world bank 8 odds ratio or similar estimates and their respective confidence intervals for every unique risk estimate involving a specific indicator and the uptake of testing initiating art and adhering to art were extracted when available statistical analysis descriptive statistics were used to examine patterns across countries with respect to proportion of factors studied in relation to access to hivaids care estimated effect sizes identified for each factor and the precision around the estimates additionally metaanalysis was done for nine specific sociocultural factors identified by the studies as statistically significantly associated with adherence to antiretroviral therapy despite the expected heterogeneity within the review we assessed the comparability of the results from individual studies using the i 2 statistic for quantifying inconsistency an overall i 2 testvalue greater than 60 was considered as indicative of a high level of heterogeneity for which statistical pooling was not appropriate further analyses included sensitivity analysis performed by removing the studies that contributed to the heterogeneity in the metaanalysis and subgroup analyses to compare highincome countries with lowincome countries a pvalue of less than 005 was considered statistically significant analyses were performed in stata 121 results study selection the primary search strategy identified 1671 potentially relevant citations after searching for duplicates 715 citations were discarded initial title and abstract screening excluded 815 manuscripts based on the inclusion exclusion criteria the remaining 141 were then retrieved for full text review a further 86 manuscripts were excluded as not meeting the inclusion criteria the remaining 55 manuscripts were quality appraised and 21 were excluded as they did not deal with confounding in their analysis thirtyfour articles were included in our analysis figure 1 displays the flow chart of the selection process study characteristics all 34 included studies employed a quantitative methodology and used structured questionnaires to determine potential factors 13 studies were conducted in low income countries 11 12 13 14 15 16 17 18 19 20 21 22 23 and 21 in high income countries the studies conducted in low income countries included one from cameroon 11 zambia 12 nigeria 13 peru 14 ethiopia 15 kenya 16 ghana 17 uganda 18 vietnam 19 india 20 tanzania 21 zimbabwe 22 and malawi 23 from high income countries nine studies were from usa 2628303334 39 40 41 42 four from south africa 31353644 three from brazil 273738 and one each from italy 24 denmark 25 australia 29 thailand 32 and china 43 a total of 29 studies were clinic based 11 12 13 14 15 16 18 19 20 21 24 25 26 27 28 29 30 31 32 33 34 35 37 38 39 40 42 and five were situated at community level 1722233644 twentyfour studies focused on adherence to art 11 12 13 14 15 2021 24 25 26 27 28 29 30 32 33 34 35 36 37 38 39 41 42 43 five studies focused on uptake of voluntary and counselling testing 1722233644 four on art initiation 16181926 and one on attrition 31 table 1 displays the characteristics of the studies factors measured by quantitative surveys to study access to hivaidscare in highand lowincome countries 12 factors were identified as measured by the studies to assess access to hiv care sociodemographic socioeconomic medical health system knowledge and beliefs risky health behaviours psychosocial stigma and discrimination family interpersonal violence communication about hivaids and community prevalence table 2 shows an outline of the factors identified per study comparative analysis showed important divergences across countries surveys in low income countries tended to focus on the study of sociodemographic socioeconomic and health system factors in relation to access to hivaids services 242527293132 34 35 36 37 38 39 40 42 43 44 while in high income countries the emphasis was on medical and psychosocial conditions 25 26 27 2932333538 40 41 42 figure 2 graphically displays the distribution of factors by country sociodemographic economic clinical and sexual behavioural factors were considerably measured in all surveys conducted in low and high income countries while interpersonal relationships communication and interpersonal violence factors remained highly understudied in both low and high economic countries table 3 displays the ranking of factors by the proportion of studies where they were included reported risk factors significantly associated with access to hivaids services across countries nonuptake of hiv testing in high income countries was associated with sociodemographic constructs such as being black 44 being between 25 to 34 years old and living in a community with high hiv testing refusal rates 23 other barriers included high risk sexual behaviours 36 such as multiple sexual partners and not using condoms and enacted stigma 39 in low income countries the barriers associated to hiv testing included belonging to the age group from 25 to over 45 1722 having unprotected sex and having sex with a nonspousal or noncohabiting partner 17 and anticipated stigma 1722 nonuptake of art in high income countries was only statistically significantly associated with having other competing subsistence needs 26 in low income countries the barriers to initiate art included indirect costs of health care not having a known hivpositive family member nondisclosure of hiv status and having additional pregnancies 111920 in high income countries low adherence to art was associated with being black 4144 being between 2534 years old 2741 and having less than primary education 27 other barriers were clinical and treatment factors such as protease inhibitor art regimens 34 frequent doses of art 2937 experience of side effects 3438 feeling unhappy with the treatment 25 initiating the treatment with a cd4 count over 200 cellsml3 31 alcohol andor substance abuse 24 27 28 29 33 and anticipated and internalized stigma were associated with low levels of adherence 29333539 in low income countries age groups associated with low adherence to art were 1930 years and over 50 years 21 the latter deviate from the risk age reported from high income countries where being over 50 was found to be protective other risk factors included having a main couple but not living together 11 being muslim 13 being female 14 food insufficiency 14 and household financial problems 1115 alcohol abuse and experienced discrimination were associated with low adherence also in low income countries 11 with respect to clinical and treatment factors in low income countries initiation of art with cd4 over 200 cellsml3 being on art less than 15 months 1315 and having switched art regimen 11 were associated with low adherence health system barriers included arv stock outs inadequate communication with health staff 111321 and health care indirect costs 111920 one study reported an inverse association between free cost of arv and adherence 20 concerning interpersonal and psychosocial factors perceived lack of family support 11 not having disclosed to the family members 19 and feeling depressed 20 were negatively associated with adherence reported protective factors significantly associated with access to hivaids services across countries in high income countries protective factors for uptake of hiv testing were being female 3644 having a history of previous illnesses 31344144 having disclosed andor having conversations about hivaids with parents 44 and believe that most people do not want to get tested for hiv or do it only if they are sick 3644 in low income countries being educated beyond primary school 17 single 22 affiliated to non christian religions 17 living in a high prevalence community 22 knowing someone infected with hivaids 22 practicing safer sexual behaviours such as using condoms and being exposed to media 1722 were positively associated with uptake of testing in low income countries belonging to the age group 30 to 40 years of age and having greater than a primary school education facilitated initiation of art 18 not drinking alcohol in the past year was also a protective factor 22 no protective effects were reported from high income countries in high income countries being older than 50 years of age 29 and on art treatment for more than two years were positively associated with adherence to art 35 previous illnesses or having other health conditions were positively associated with good adherence 31344144 selfperception of good health status 3538 and no consumption of alcohol in the past year 30 were also protective good family communication 3242 higher levels of treatment information 35 and believing in the benefits of arvs 28 were facilitators of adherence in low income countries good social support and selfefficacy were positively associated with adherence as well as having disclosed to at least one family member about ones positive hiv status 1314 experiencing other health conditions was also associated with a protective effect on adherence 31354144 no studies reported significant risk effects for defaulting combined effect sizes associated with adherence the pool estimates of the 34 studies which included sociocultural factors are shown for a general sociodemographic factors and b specific sociocultural factors due to an insufficient number of studies for other outcomes only adherence could be included in the model the metaanalysis showed that being male was associated with optimal adherence in low income countries while the association with being female was not statistically significant conversely sociocultural factors associated with lower adherence included perceived lack of social support although sufficient data were available only in high income countries perceived social stigma had an overall risk factor in both settings high risk health behaviours such as alcohol abuse and abuse drugs were also significant in both settings while low levels of selfefficacy were negatively associated with adherence in both settings this effect was stronger in high income countries than in low income countries absence of symptoms of depression was positively associated with optimal adherence in both settings tables 4 and5 summarize the meta estimates of the sociodemographic and sociocultural factors respectively discussion this review revealed a trend in quantitative survey studies to explore the same kinds of factors in relation to access to hivaids services overall the most studied factors in all regions including africa asia latin america and some groups and communities in north america were socioeconomic medical and health risk behaviour in lowincome countries the research focus was on socioeconomic and health system factors while in highincome more attention was given to clinical and psychosocial factors such as depression anxiety selfefficacy andor sexual identity sociocultural factors including social and family support interpersonal violence and disclosure about hivaids received in comparison very little attention in both rich and poor countries these results should call the attention of survey researchers and systematic reviewers the aforementioned sociocultural factors have been widely published in qualitative studies 2 3 4 5 6 as critical factors that influence access to hivaids services both in high and in low income countries however most of the quantitative studies included in our review from both high and low income countries omitted them in their surveys or explored them very superficially this is not justified as these factors are key issues for survey research our results suggest that the problem lied in the exclusion of qualitative information in the questionnaire design of the 34 studies included in this review 27 12 13 14 15 16 17 18 20 22 23 24 2728 30 31 32 33 34 35 36 38 39 40 41 42 43 44 used validated measures from previous quantitative studies to derive their questionnaires and only seven studies three in low income countries 111921 and four in high income countries 25262937 conducted an informative phase using qualitative methods to inform the questionnaire development the exclusion of qualitative information during the questionnaire design in the rest of the studies could have led to overemphasis in the research of the same kind of easily measured variables this compromises the interpretation and generalization of the evidence and its application to inform health policies and programs indeed this review showed that according to the quantitative evidence the factors studied to assess the barriers to access hivaids services inexplicably differ between richer and poorer countries contrary to the evidence from qualitative studies additionally due to an insufficient number of consistent studies for other outcomes only adherence outcomes could be metaanalysed the metaanalysis of the other outcomes proved untenable as the wide range of instruments and indicators used to assess sociocultural variables such as social support stigma depression and selfefficacy introduced too much heterogeneity in the studies and impeded the pooling and synthesis of the results table 6 shows the variability of the instruments used to assess the same indicator risk factors of lowadherence in both rich and poor countries were stigma and discrimination alcohol and drug abuse depression and low selfefficacy social support was the only factor that showed a protective effect yet it is unclear whether this effect occurred equally in rich and poor countries as enough data were available only from high income countries the comparative approach between high and low income countries of this systematic review and metaanalysis has several advantages over pooling all countries included in the review this comparative nature yielded valuable information about the differences and similarities of social and cultural processes that affect access to treatment in each context the comparison also reveals a potential bias in the factors studied in the different regions that may be motivated by cultural stereotypes and has also facilitated the detection of trends and the identification of gaps in the surveys conducted which otherwise would have remained in the shadows thus this comparative approach has helped to produce a more detailed description of these gaps which can be beneficial for the preparation of future surveys in this field there are several limitations to our study publication bias may be limiting our systematic review of quantitative studies although we have used preferred reporting items for systematic reviews and metaanalyses guidelines 45 to examine reporting and other biases in a systematic way see additional file 1 for further details another limitation is the difference between the timing of the preparation of the surveys and the one of the publications of qualitative studies we would not expect a survey published in the early 90s to be aware of the problems identified in qualitative studies published later but our analysis indicates that in general the quantitative studies have not systematically addressed important issues identified in qualitative studies that were published at least two years before the implementation of their surveys conclusions this review has highlighted a number of issues requiring further research and demonstrated the need to improve the research strategy in epidemiological survey studies improvement of this strategy requires better integration of the findings of qualitative studies in quantitative surveys and more consistency between survey studies this review also offered evidence of the lack of consistency in the measurement of sociocultural factors which hinders comparisons between studies we recommend that prior to developing a questionnaire literature reviews should be systematically carried out including qualitative studies this would help to identify appropriate themes for the context avoiding the tendency to focus on the same topics we further recommend using validated instruments giving priority to cultural adaptations over the development of new measures we also call for a generalization of some variables without limiting the specificity of the various contexts for example it would be useful to report the effects of different types of stigma as defined by subscales of validated tools rather than global scores which cannot be disentangled and are less informative another example is the social support measure which could also be broken down by subtypes material emotional etc further quantitative research is needed on sociocultural determinants of hiv testing initiation of antiretroviral therapy and defaulting in both lowand highincome countries more consistency between qualitative and quantitative research and between quantitative measures of sociocultural factors will help to increase the quality of the data collected to enhance comparability which is a prerequisite for metaanalyses to avoid duplication and in general to produce better scientific evidence to inform managers and policymakers working on hivaids additional file additional file 1 prisma 2009 checklist competing interests the authors declare that they have no competing interests

background the role of sociocultural factors in influencing access to hivaids treatment care and support is increasingly recognized by researchers international donors and policy makers although many of them have been identified through qualitative studies the evidence gathered by quantitative studies has not been systematically analysed to fill this knowledge gap we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which sociocultural determinants of access identified through qualitative studies have been addressed in epidemiological survey studies methods ten electronic databases were searched cinahl embase isi web of science ibss jstor medline psyinfo psyindex and cochrane two independent reviewers selected eligible publications based on the inclusionexclusion criteria metaanalysis was used to synthesize data comparing studies between low and high income countries results thirtyfour studies were included in the final review 21 62 done in high income countries and 13 38 in low income countries in low income settings epidemiological research on access to hivaids services focused on socioeconomic and health system factors while in high income countries the focus was on medical and psychosocial factors these differences depict the perceived different barriers in the two regions common factors between the two regions were also found to affect hiv testing including stigma high risk sexual behaviours such as multiple sexual partners and not using condoms and alcohol abuse on the other hand having experienced previous illness or other health conditions and good family communication was associated with adherence to art uptake due to insufficient consistent data a metaanalysis was only possible on adherence to treatment conclusions this review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to hivaids services the evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design with the changing face of the epidemic we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys

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friendships often serve as a source of connection and happiness in late life partly because many of these relationships have endured for years indeed friendships differ from other types of relationships because they are voluntarily chosen and can be disbanded without a formal process or even formal acknowledgment moreover functionalist theory identifies specific functions that friends may serve to enhance older adults lives in a way that other social partners do not compared to other social partners friends are better at providing companionship for leisure activities developing and maintaining personal meaning and selfidentity and providing shortterm help and emotional support however we know little about older adults experiences with friends throughout the day because prior studies focused on retrospective reports on the general quantity and quality of friendships in late life in this study we examine the affective features of older adults experiences with friends when compared with other types of social partners using an ecological momentary assessment methodology this methodology allows us to capture older adults emotional experiences without relying on retrospective recall of relevant experiences daily experiences with friends encounters with friends are common in older adulthood on average older adults report having contact with a friend at least once a week indeed the companionship that even casual friends provide is crucial for wellbeing higher levels of companionship buffer the effects of minor stressors on wellbeing and are more strongly associated with loneliness and relationship satisfaction than social support pleasantness older adults encounters with friends are usually pleasant according to socioemotional selectivity theory older adults tend to engage in behaviors that maximize pleasant experiences unlike family relationships which cannot be terminated easily the voluntary nature of friendships allows older adults to dissolve unsatisfactory friendships from their networks likewise the social convoy model suggests some social partners may drop out due to choices or external circumstances throughout the life course these network partners may either be replaced by new or existing members or may not be replaced causing the convoy to shrink in size as such many enduring friendships in late life are likely among the strongest and most rewarding ties stressful experiences social encounters can sometimes be a source of stress however research regarding stressful experiences with friends is mixed some studies find that older adults experience more tensions with nonfamily members than with family members yet retrospective studies that differentiate friends from coworkers or service providers show it is the latter two who cause aggravation indeed the similarities shared by friends may lead to fewer disagreements or conflicts with friends than with nonfriends older adults may also experience fewer stressful experiences with friends than with their partners or family members but for other reasons for example contact with friends often involves leisure activities whereas contact with romantic partners and family members may include household tasks or decisions that are potentially stressful that could lead to conflicts for these reasons we expected that older adults would report greater pleasantness and fewer discussions about stressful experiences in their encounters with friends compared to their encounters with other social partners mood contact with friends has been linked to older adults better subjective wellbeing relational regulation theory suggests that ordinary conversation companionship and fun are more closely linked to wellbeing than receiving support indicating friends could be influential for older adults wellbeing in one of the earliest daily experience studies larson and his colleagues paged older adults at random times within every 2hr block they found that positive mood states were associated with the presence of friends although daily studies on friendships are sparse we predicted that older adults would report better mood when they were with friends than when they were alone or with other social partners throughout the day closeness of friendships we examined relationship closeness and specifically whether close friends have a greater influence on older adults emotional wellbeing than less close friends do according to the social convoy model close social partners are the most likely to provide support and affirmation which have decisive influences on wellbeing similarly studies have found that older adults who have close friends or feel close to their friends report better wellbeing than older adults who have only casual friends or feel less close to their friends or lack friends as such we predicted that older adults would report greater levels of pleasantness fewer discussions about stressful experiences and better mood when they had encounters with closer friends than when they had encounters with less close friends other factors associated with encounters and experiences with friends this study adjusted for additional factors that may be associated with daily experiences with friends among older adults older age and poorer health are associated with less frequent contact with friends women have more frequent contact with friends than men as do people with higher socioeconomic status relative to those with lower ses further african americans and hispanics are less involved in friendship networks than white americans we also adjusted for the proportion of friends each participant reported in the social convoy beyond participant factors we also adjusted for inperson contact given that facetoface contact is associated with better emotional wellbeing further we considered the number of different types of activities in which participants engaged referred to here as diverse activities prior studies have found that greater diversity of behaviors is associated with better mood the current study the current study tested the following hypotheses compared to other encounters throughout the day we expected that older adults would hypothesis 1 evaluate encounters with friends as more pleasant hypothesis 2 be less likely to discuss stressful experiences in their encounters with friends hypothesis 3 report better mood when they had encounters with friends we also expected that the associations in h1h3 vary by closeness hypothesis 4 compared to encounters with less close friends throughout the day we expected older adults would evaluate their encounters with close friends as more pleasant be less likely to discuss stressful experiences and report better mood methods participants and procedures the current study used data from the daily experiences and wellbeing study collected in 20162017 this study included 333 adults aged 65 and older who resided in the greater austin texas inclusion criteria involved residing in the community and not working fulltime for pay participants first completed a 2hr initial interview at home or in a location of their choice they then completed emas on their social experiences every 3 hr each day across 5 or 6 days using an android device provided to them they received 50 for completing the initial interview and another 100 for completing the ema of the 333 older adults who completed the initial interview 313 participated in the ema compared to the other 20 participants who were not part of the daily data collection these 313 participants were less likely to selfidentify as an ethnic or racial minority but did not differ in other background characteristics the number of friends participants listed in the top 10 divided by the total number of social partners listed in all the social convoy circles coded as 1 and 0 e coded as 1 and 0 f the proportion of assessments in which older adults had encounters with friends g the proportion of assessments in which older adults had encounters with romantic partners h the proportion of assessments in which older adults had encounters with family members i the proportion of assessments in which older adults had encounters with others j averaged rating of pleasantness of encounters rated from 1 to 5 k averaged proportion of discussions of stressful experiences coded as 1 and 0 l average of four positive mood items every 3 hr rated from 1 to 5 m average of five negative mood items every 3 hr rated from 1 to 5 summarizes the 313 participants demographic and daily experiences information initial interview measures social convoy in the initial interview participants listed their social partners in three concentric convoy circles participants provided names of people they feel so close to that it is difficult to imagine life without them may not feel quite that close to but who are still very important to them and have not already mentioned but who are close enough and important enough in their lives that they should also be included in the circle social partners are predominantly spouses children siblings and friends to avoid fatigue participants only answered additional questions for up to 10 of their closest social partners we generated a categorical variable to indicate relationship types 1 2 3 and 4 covariates participants age gender coded as 1 and 0 ethnicracial minority status recoded as 1 and 0 health status selfreported on scale from 1 to 5 and education level coded as 1 2 3 4 5 6 7 to 8 were assessed we generated a variable to indicate the proportion of friends in the social convoy we did not include relationship status as a covariate due to the high correlation between relationship status and encounters with romantic partners which may cause multicollinearity ema measures encounters with social partners every 3 hr participants reported whether they had any social encounters with each of their 10 closest social partners listed in the convoy model we had information about these social partners relationships to the participants from the global interview after completing this part of the survey participants also indicated how many people they had encountered who were not already listed during the prior 3 hr then participants answered additional questions on up to the six of these additional social encounters including their relationship type we treated the nonconvoy family members in the category of family members nonconvoy friends as friends and the remaining nonconvoy social partners as other social partners closeness of friendships the social convoy measure asked participants to list social partners who were important in their lives we generated a variable to indicate whether the friend was listed in the convoy or reported as an additional social contact 1 and 0 pleasantness of the encounter for each social encounter the participant reported in the prior 3 hr a followup question asked how pleasant was this interaction for you participants rated each encounter from 1 to 5 stressful experiences in addition to the rating of pleasantness for the encounter another followup question asked did you discuss anything that might be considered stressful or unpleasant participants answered 1 or 0 mood participants rated their positive and negative mood during the prior 3 hr they rated the extent to which four positive mood items and five negative mood items described them on a scale from 1 to 5 we calculated averages to generate a positive mood score and a negative mood score covariates participants also indicated how they encountered each of their social partners inperson via text or phone we generated a variable to indicate whether each encounter was an inperson contact 1 or 0 for analyses at the encounter level for ratings of mood we used the proportion of encounters that were inperson contact during each assessment in addition participants indicated whether they engaged in 14 sets of waking activities every 3 hr we generated a sum score to indicate the diversity of activities every 3 hr analytic strategy to test the first two hypotheses whether older adults encounters with friends were more pleasant and less likely to discuss stressful experiences compared to encounters with other encounters we estimated multilevel models to account for encounters with different social partners being nested within 3hr assessment intervals and within participants we estimated multilevel linear models with sas proc mixed for the continuous outcome and multilevel logistic models with sas proc glimmix for the binary outcome the predictor a categorical variable representing four types of social partners was dummy coded such that friend was the referent group and romantic partner family member and another social partner were entered as predictors or 0 for each across the two models the study focused on withinperson effects we followed the recommended statistical procedures for examining withinperson effects by including the betweenperson effects that is we included each participants mean variables in the threelevel models to adjust for possible betweenperson effects the betweenperson centered variable was calculated by taking the proportion of encounters across the study that each participant had with friends and subtracted the mean of all participants proportions of encounters with friends this same process was used to calculate betweenperson centered variables of romantic partner family member and another social partner before running the models we grandmean centered the covariates age level of education health status and proportion of friends and effectcoded for gender minority status and inperson contact to make the intercepts more interpretable to assess differences between these social partners associations with the rating of pleasantness and discussions about stressful experiences we tested all pairwise comparisons of the withinperson effects with tukey adjustments after running the models to test the next hypothesis pertaining to older adults mood we estimated twolevel models with 3hr assessment intervals nested within participants using sas proc mixed we treated older adults positive and negative mood as continuous outcomes in two separate models participants could have encountered multiple types of social partners in the same 3hr period thus in these analyses we entered variables representing whether the participant had any encounters with each type of social partner friends 1 and 0 romantic partners 1 and 0 family members 1 and 0 and other social partners 1 and 0 these dichotomous variables represent any encounter with any person in that category rather than the number of social partners encountered for twolevel models we were also interested in the withinperson effects similarly we included each participants mean variables in the twolevel models to adjust for the betweenperson effects models examining mood adjusted for the same covariates in the previous models except that we adjusted for the proportion of encounters that occurred in person during each assessment and number of diverse activities in which participants engaged we conducted pairwise comparisons using ttests to determine whether the coefficients for encounters with different types of social partners significantly differed from one another that is we asked whether links between certain encounters and mood were stronger than links involving other encounters we reestimated the model for each of these outcomes by comparing convoy friends and nonconvoy friends in the analyses pertaining to pleasantness and discussion about stressful experiences we selected encounters when participants reported encounters with friends and excluded the times when participants reported encounters with other types of social partners or no encounters at all therefore the predictor was a dichotomous variable that represented whether that encounter with a friend was a social convoy friend 1 and 0 we reran the analyses involving mood by entering any encounters during the prior 3 hr with convoy friends 1 and 0 and nonconvoy friends 1 and 0 as predictors in addition to any encounters with romantic partners family members and other social partners results the total sample of older adults listed an average of 210 friends in their social convoy representing 17 of their overall social convoy members older adults encountered friends in about onethird of their assessments more than 90 of older adults encountered at least one friend during the study period among all the encounters with friends 32 of these encounters involved convoy friends and 68 of these encounters were with nonconvoy friends withinperson differences in friendship experiences pleasantness of the encounters we hypothesized that older adults evaluated encounters with friends as more pleasant compared to encounters with other social partners throughout the day as expected older adults viewed their encounters with friends as more pleasant compared to encounters with romantic partners family members or other social partners supplementary table 1 shows findings from pairwise comparisons of the other relationships using tukeys adjustment stressful experiences we also predicted that older adults were less likely to discuss stressful experiences in their encounters with friends compared to their encounters with other social partners as given in table 3 older adults were less likely to discuss stressful experiences when they encountered friends than when they encountered their romantic partners or family members yet older adults were more likely to discuss stressful experiences in their encounters with friends compared to encounters with social partners other than family members pairwise comparisons of discussions of stressful experiences among other relationships using tukeys adjustment are presented in supplementary table 1 mood we then explored how encounters with friends were associated with older adults mood throughout the day as given in table 4 encounters with friends were associated with increased positive mood throughout the day pairwise comparisons using ttests revealed that encounters with friends were more strongly associated with positive mood than encounters with other social partners yet we did not observe a significant association with negative mood closeness of friendships we reestimated all models and considered the differences between convoy friends and nonconvoy friends we found no significant differences between convoy friends and nonconvoy friends on the rating of pleasantness or discussions of stressful experiences in their encounters with regard to mood we observed interesting withinperson effects as given in table 5 encounters with nonconvoy friends were significantly associated with increased positive mood and reduced negative mood even after accounting for encounters with romantic partners family members and other social partners ttests comparing the effect sizes further revealed that encounters with nonconvoy friends were more strongly associated with higher positive mood than encounters with convoy friends the ttests for negative mood was not significant betweenperson differences in friendship experiences our findings revealed that older adults who encountered friends more often during the study period were no different in their reported pleasantness frequency of discussion of stressful experiences or either positive or negative mood from participants who encountered friends less often by adjusting for the betweenperson effects we ensured the observed findings were not because participants had more total number of encounters with friends during the study period post hoc tests we also asked whether the pleasantness and discussions about stressful experiences during the encounters mediated the association between encounters with friends and positive mood we estimated twolevel mediation models using mplus with 3hr assessment intervals nested within participants adjusting for the covariates used in prior models testing mood we generated mean variables to indicate the rating of pleasantness and discussions of stressful experiences during the 3hr assessment findings revealed that encounters with friends had a significant indirect effect on positive mood via the averaged rating of pleasantness but there was no significant indirect effect via averaged discussions of stressful experiences daily experiences with friends also may vary depending on relationship status with older adults who lack a romantic partner perhaps experiencing more frequent encounters with friends and stronger emotional reactions to these encounters we explored whether relationship status moderated the associations between encounters with friends and pleasantness of the encounter discussions of stressful experiences or mood we did not include encounters with romantic partners given the high correlation between relationship status and encounters with romantic partners findings revealed a significant interaction between relationship status and encounters with friends for pleasantness and positive mood simple slopes analyses revealed that older adults who were not marriedcohabitated reported significantly greater pleasantness when they encountered friends than did marriedcohabitated older adults and more positive mood we did not observe significant interaction effects of encounters with friends × relationship status on discussions of stressful experiences with friends or negative mood discussion friendships are strongly associated with older adults wellbeing yet prior research findings are predominantly based on retrospective reports between the number or quality of friendships and wellbeing this study examined how daily contact with friends shapes daily experiences using emas we found that contact with friends was common in older adults everyday lives and played a stronger role in older adults daily emotional wellbeing than did other relationships encounters with friends and daily experiences pleasantness as hypothesized older adults reported greater pleasantness during their encounters with friends than during encounters with other types of social partners socioemotional selectivity theory predicts that close social partners among older adults generate more positive emotional experiences than do acquaintances our current study parallels with these studies and finds that encounters with friends are the most pleasant even beyond the encounters with romantic partners or family members this is possible because older adults spend more time with their romantic partners or family members they may habituate to encounters with these people an encounter with a friend on the other hand may represent a positive change in daily activities stressful experiences our findings also revealed that older adults were less likely to discuss stressful experiences in their encounters with friends than in their encounters with romantic partners or family members these findings are consistent with the relational ambivalence literature which suggests older adults are less likely to have negative exchanges with friends than with family members however it is worth noting that discussing stressful experiences does not necessarily indicate the encounter per se was stressful individuals may discuss stressful issues with friends as a way to garner support nevertheless we were also surprised to find that encounters with other social partners were even less likely to discuss stressful experiences than encounters with friends romantic partners or family members this lower rate of discussing stressful experiences may reflect a lack of investment and commitment in these distal social partners such that older adults do not bother to raise annoying issues or generate conflicts with these distal social partners mood consistent with prior retrospective studies we found that encounters with friends and family members were associated with increased positive mood throughout the day encounters with friends were more strongly associated with positive mood than encounters with other social partners but did not differ significantly from romantic partners or family members it appears to be the case that both encounters with friends and family members play an equally important role in enhancing positive mood among older adults however we did not observe a reduction in negative mood when older adults encountered friends this might due to a lack of variability in negative mood among older adults closeness of friendships and daily experiences as noted earlier socioemotional selectivity theory suggests older adults tend to retain their closest social partners and engage more often with these partners likewise older adults are expected to engage more often with close friends than less close friends surprisingly our findings revealed the opposite our finding provides evidence that older adults maintain some dormant friends who are viewed as important but are not frequently encountered the social convoy literature documents the influential role of social convoy partners on ones wellbeing yet our findings revealed no association between closeness of friendships and momentary ratings of pleasantness or discussions of stressful experiences in their encounters with friends however interestingly although encounters with nonconvoy friends were associated with increased positive mood and reduced negative mood we found that encounters with convoy friends were not our findings added support to the literature on the importance of peripheral ties which suggests less close ties are beneficial in terms of social integration diverse activities and novelty further relational regulation theory posits that global perceptions of support are not based on the actual instances of support but on other pleasant exchanges in the relationship in this case although less close friends are unlikely sources of support encounters with these friends are associated with better mood because these encounters may entail fun and companionship indeed encounters with nonconvoy friends may involve novel experiences compared to more routine activities with closer friends and family several studies have documented that novelty is associated with happiness our findings parallel those findings by revealing that contact with less close friends was associated with better mood in older populations friendship experiences and relationship status most research suggests that unmarried older adults have more friends on average and are more likely to socialize and exchange help with friends compared to their married counterparts our findings extend this research by showing that older adults who were not married reported greater pleasantness and more positive mood when they encountered friends than married older adults thus friends may constitute a key part of social networks for older adults who are widowed divorced or never married limitations and future directions limitations of this study should be addressed in future research the study was correlational so causal relationships could not be determined researchers should examine potential mechanisms that explain associations between encounters with friends and emotional wellbeing future research could consider the content of the encounters to better understand observed associations for example individuals usually perform routine daily tasks with their family members whereas friends often serve as companions for social activities furthermore this study did not isolate encounters with friends from the cooccurrence of other social encounters during the 3hr period it is possible that an unpleasant or pleasant experience with one social partner may affect the concurrent or subsequent social experience with another social partner the measures also did not examine participants understanding of friendship some older adults may view their closest friends as family members moreover older adults may feel close to friends who are not listed in the top 10 of their convoys as such future research should pay more attention to the complexity of this friendship variation as noted earlier older adults may have close friends that they rarely contact in daily lives but are crucial to their wellbeing future research should differentiate effects of friends who are rarely encountered from friends who are encountered on a daily basis lastly research could also examine friendship characteristics other than closeness such as the gender and age of friends or relationship duration together findings suggest that friends play a unique role in older adults emotional wellbeing and they do so by increasing levels of positive experiences encountered in daily life moreover this study explored the closeness of friendships and provided a window to understand the complexity of friendship supplementary material supplementary data is available at the journals of gerontology series b psychological sciences and social sciences online conflict of interest none reported

objectives having friends in old age is linked to higher levels of happiness and life satisfaction yet we know little about older adults emotional experiences when they encounter friends throughout the day this study examined whether older adults reported a more pleasantness b fewer conversations about stressful experiences and c better mood when they had contact with friends compared to when they had contact with other social partners or were alone throughout the day we also examined whether these experiences varied by the friendship closeness method adults aged 65 n 313 from the daily experiences and wellbeing study provided background information and listed and described their close social partners participants then completed ecological momentary assessment ema surveys every 3 hr for 5 to 6 days where they reported their encounters with social partners rated the pleasantness and indicated whether they discussed stressful issues during these encounters and rated positive and negative mood results multilevel models revealed that encounters with friends were more pleasant and were associated with fewer discussions about stressful experiences compared to encounters with romantic partners or family members throughout the day encounters with friends were also associated with better mood though this link only held for encounters with friends who were not considered close discussion findings are discussed in terms of functionalist theory socioemotional selectivity theory relationship ambivalence and the benefits of less close ties this work facilitates the understanding of how daily contact with friends can promote older adults emotional wellbeing

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introduction c rosssectional and longitudinal studies have consistently found that having frequent family meals is associated with multiple health benefits for children and adolescents including healthful dietary intake 1 2 3 4 lower levels of unhealthy weight control behaviors 5 and better psychosocial wellbeing 6 in addition associations between family meal frequency and lower child weight status have been found however not all findings have been consistent 178 although there have been numerous quantitative studies examining the association between family meal frequency and child and adolescent weight and weightrelated behaviors 1 2 3 4 5 6 7 8 limited qualitative research has been conducted to understand more in depth about family meallevel characteristics occurring during family meals that may explain the association between family meal frequency and child weight status in addition no studies that we are aware of have compared family meals in households where there is a child who is overweightobese and households where there is a child who is normal weight understanding how family meals operate in households with and without an overweightobese child will help to identify potential risk and protective factors related to family meals that may be linked to child weight and weightrelated behaviors further identifying family meallevel characteristics in households with normal weight children could inform targets for interventions to reduce childhood obesity the majority of the previous qualitative research on family meals has not included raciallyethnically and socioeconomically diverse populations 9 has focused more on barriers and problems with carrying out family meals 10 11 12 or has examined the benefits of family meals and why families have family meals 10 12 13 14 thus more qualitative research is needed examining multiple family meallevel characteristics with raciallyethnically and socioeconomically diverse families in order to understand more in depth why family meals may be protective for child weight and weightrelated behaviors the main aim of the current study is to identify family meallevel characteristics that are similar andor different in raciallyethnically and socioeconomically diverse households with and without an overweightobese child the main research questions included do parents report similar or different reasons for having family meals in households with and without an overweightobese child do parents report similar or different rules during mealtimes in households with and without an overweight obese child do parents report similar or different child behaviors during family meals in households with and without an overweightobese child and do parents report similar or different meal preparation behaviors in households with and without an overweightobese child methods sample the current study utilized data from the family meals live study 15 family meals live is a mixedmethods crosssectional study designed to identify key family home environment factors related to eating behaviors that increase or minimize the risk for childhood obesity participants were recruited through primary care clinics located in lowincome and minority neighborhoods a flier was sent to the childs home inviting the family to participate in a study examining family and home influences on child eating behaviors and child weight status interested parents would call research staff who would set up an appointment for the first home visit where child weight status was confirmed and all family members were assentedconsented into the study eligibility criteria included children between the ages of 6 and 12 years and their families families who ate at least three family meals per week and no child illness disorder that would interfere with child eating behaviors or nutrition families participated in two home visits the first home visit included conducting a home food inventory a 24hour child dietary recall with the primary caregiverparent collection of heights and weights on all family members and the beginning of an observation period where families would videorecord their family meals for 8 days in between the two home visits parents participated in another 24hour child dietary recall in the second home visit parents participated in the final 24hour child dietary recall and individual interviews were conducted with the parent detailed study methods are described elsewhere 15 given the intense involvement of the study participants were given the ipad that was used to videorecord their family meals as their study incentive this helped ensure that the ipads would not get lost and would be well taken care of the university of minnesotas institutional review board human subjects committee approved all study procedures the study included 120 children and their primary caregivers children were between the ages of 6 and 12 and 46 were girls the primary caregivers were mostly women with a mean age of 35 years parents and children were raciallyethnically diverse and from lowincome households a little over 50 of the caregivers were unemployed or stayathome caregivers by design of the study 50 of the sample was classified as overweight obese and 50 were normal weight in order to identify potential risk and protective factors for childhood obesity in the home environment for the current study 118 individual parent interviews were used in the qualitative analysis individual interviews were used versus focus group methodologies in order to gain more specific familylevel information about the home food environment interview development and data collection an interview guide was developed based on peerreviewed research on family meals and findings from the family meals live pilot study 1216 interviewers were trained using standardized qualitative interview protocols 17 individual interviews followed a semistructured openended question format using followup probing questions by the interviewers to elicit expansion of participant responses 17 the qualitative interview questions aimed to understand parents perspectives regarding potential risk or protective factors for childhood obesity in the home environment questions included statistical analysis audiorecorded interviews were transcribed verbatim and coded using a deductive and inductive content analysis approach 18 19 20 this hybrid approach allowed for using a priori categories such as our research questions to guide our analysis while at the same time allowing for themes to naturally emerge from the data two members of the research team independently read and coded the interviews using nvivo 10 software using open coding the researchers read through each interview line by line to establish initial codes and capture key thoughts and concepts next coding to reduce broad categories into subcategories was conducted and major concepts were identified the major concepts were further defined developed and refined into main themes after completing the coding the interviews were stratified into two groups based on child weight status allowing for similarities and differences in themes to naturally emerge between the two groups fiftynine interviews were categorized in the overweightobese group and 59 interviews were categorized into the normal weight group interrater reliability was established with both coders coding 10 of the interviews consistency between the coders was assessed using the formula number of agreements divided by total number of agreements plus disagreements 21 intercoder reliability was established and maintained at 95 discrepancies were discussed between the two coders and the larger research team until 100 consensus was achieved 22 any qualitative themes between households with and without an overweightobese child that reached a 20 or more difference are discussed below in order to understand potential important differences that can be followed up with large quantitative samples results overall results indicated that there were both similarities and differences in themes regarding family meallevel characteristics between households with and without an overweightobese child these similarities and differences will be reported below by research question all names in qualitative quotes have been changed for confidentiality two differences between households with and without an overweight obese child regarding reasons for having family meals research similarity to feed childrenfamily over 30 of families with and without an overweightobese child said that they had family meals because they needed to feed their childrenfamily anyway and that having family meals were one way to make sure that happened one father with a normal weight child stated we gotta eat one mother with an overweightobese child said its legal i have to feed the children another mother with a normal weight child stated well i have a family andwe got to eat similarity feeding childrenfamily more healthfully over 35 of families with and without an overweightobese child reported that they had family meals because it allowed them an opportunity to feed their children more healthfully one mother with an overweightobese child said that she had family meals to keep my family healthy another mother with an overweightobese child said family meals are important for my family because we eat healthy food one mother with a normal weight child said i want to keep my kids healthyfamily meals is a good opportunity to do that difference communicationconnection over 60 of families with normal weight children identified communication and connection as main reasons for having family meals compared to 34 of families with overweightobese children in the home for example one mother with a normal weight child said family meals are a time to come togetheryou know we pray and we talk about the day things that we did and whats to one father with a normal weight child stated we feel that its family meals important because it gives us at least fifteen to twenty minutes to really be with each other we do quite a bit of discussion during that time how did your day go what happened gives us a little bit more oneonone time with the kids too we dont always get that otherwise difference tradition over 40 of families with overweightobese children identified that tradition was one of the reasons they had family meals compared to 20 of families with normal weight children in the home one mother from a household with an overweightobese child said its family meals just family tradition youre supposed to have family meals another mother with an overweightobese child stated i think its family meals very important from generation to generationwe go to grandmas we all eat the same meal just sit and eat one father with an overweightobese child said we have family meals together because thats the way i was raisedcoming to a family meal was importantit was something that was expected and we were there so i continue that tradition with our family research question 2 do parents report similar or different rules during family meals in households with and without an overweightobese child results indicated two similarities and two differences between families with and without an overweightobese child regarding rules during family meals similarity rules about manners over 65 of families with and without an overweightobese child indicated that they used rules about manners during family meals one mother with a normal weight child said my rules are basically good mannersthey can talk but its no food in the mouth or when theyre done they put their dishes in the sink and wash them and everybody has to come and eat at the same time another mother with an overweightobese child stated my rules are elbows off the table sit still when youre eating be quiet when youre eating no fighting at the table no arguing with each other one father with a normal weight child said manners thats one of the things we try to emphasize wash your hands before you come to dinner be respectful at the table similarity at least try it approximately 50 of families with and without an overweightobese child said that they had a rule at family meals that everyone had to at least try it one father with a normal weight child said you dont have to eat everything as long as you try it if youre not hungry just eat a little something one mother with an overweightobese child stated i like them to try at least try it that is something i do say you have to at least try it dont say you dont like it just because of the way it looks and its different another mother with a normal weight child said its dinner so you got to at least try somethingi mean you dont have to eat it all but you have to eat something and sometimes your child will be like i dont want to i dont want to okay eat five big bites and then you can be done you know that type of thing so you have to eat something you know there is no im just done no difference clean your plate approximately 60 of families with an overweightobese child endorsed a clean your plate rule compared to only 21 of families with a normal weight child in comparison 37 of families with a normal weight child in the household reported intentionally not using a clean your plate rule compared to 8 of families with an overweightobese child a mom with an overweight obese child said they have to clean their plate before they can leave the table a mother with an overweightobese child stated they cannot get up without eating they cant ask for seconds without eating everything on their plate first and they cant have something to drinkbecause they would be too busy drinking and not eating and then when they get full off of the drink then they dont want to eat anymore on the other hand families with a normal weight child endorsed that they did not have a clean the plate rule one mother with a normal weight child said we dont have the clean plate club rule at all that was a conscious choice that we made very early on that we werent going to do that one father with a normal weight child said the finish your plate rule i guess i think thats not necessarily a good thing i would rather they just stop when theyre full you know and be done with that another mother with a normal weight child stated ive never told janeeca that she couldnt leave until she cleaned her plate or she finished her food ive always told her if youre full stop eating you dont have to finish it dont stuff yourself ive always told her that and you know i dont want her to overfeed 372 berge et al herself and if she cant eat it and i got to throw it away or whatever id rather live with that then knowing that i made her forced her to eat something when she wasnt hungry so difference limits with electronic devicesscreen time families with overweightobese children differed from families with normal weight children on screentime rules with 25 more parents with overweightobese children stating that screen time was allowed during family meals families with overweight children described eating meals while watching tv as well as having the tv on but not paying attention to it one mother of an overweightobese child said i let them be i let them watch tv or use their phones to a certain extent at dinner another mother of an overweightobese child stated the tv it just stays on during mealsi dont know why my tvs always on 247 in contrast a mother with a normal weight child said tv is off during dinnertime because i think it becomes a distraction and it discourages talk amongst family members another mother with a normal weight child stated i dont bring my phone to dinner and of course she daughter cant bring any device to dinner either one father with a normal weight child stated i feel like they have plenty of time to do that stuff screen time that doesnt need to happen around mealtime ever just its not necessary its such a small amount of time at the end of the day where were all sitting down eating they dont need electronics at the meal they just dont research question 3 do parents report similar or different child behaviors during family meals in households with and without an overweightobese child results indicated one similarity and one difference between households with and without an overweightobese child regarding child behavior during family meals similarity children not wanting to sit during family meals over 40 of families with and without an overweight obese child stated that their child would not sit down during family meals one mother with an overweightobese child said that she did not like that her child was getting up going back and forth walking from the tablecoming back to the table getting up back and forth one father with a normal weight child stated they want to get up they want to eat and move around instead of just sitting and eatingthey want to come over here or go over there and turn on the tv or turn off the tv or just something they cant sit still difference child behavior problems approximately 39 of parents in households with overweightobese children reported child behavior problems during family meals compared to 15 of parents with normal weight children one mother with an overweightobese child stated i hate it when they fight because they fight a loti dont want to hear it when im eating okay another mother with an overweightobese child stated when its time to eat he dont like to come upstairs and eat he throws tantrums to a point where he just dont eat at all one father with an overweightobese child stated with four kids theres always occasional picking at this or thatparents saying come sit down and eat your meali mean just like tonight jeremiah was hopping up on the table and we were all trying to get him down and it turned into a big mess research question 4 do parents report similar or different meal preparation behaviors in households with and without an overweightobese child results indicated two similarities and one difference regarding meal preparation and carrying out family meals between households with and without an overweightobese child similarity dont like meal planning over 30 of parents from households with and without an overweightobese child stated that they did not enjoy the meal planning involved with family meals one mother with an overweightobese child stated i dont like planning what were going to eat or if what i plan no ones in the mood for thats frustrating another mother with an overweightobese child said planning the mealthat is the part that i really rather would not do if somebody would hand me a menu here you go these are foods you guys will eat that would kind of be a dream for me one father with a normal weight child stated i dont like planning mealstrying to make sure that theres something a little bit different we kind of got in the spaghetti and tacos and pizza and mac and cheese rut and so now were finding new recipesit is tiresome similarity involve children in cooking and carrying out family meals approximately 45 of parents from households with and without an overweightobese child said that they tried to involve their children in cooking the food for family meals and the logistics related to carrying out family meals such as setting or clearing the table one mother with a normal weight child said cecelia helps cook the mealsshe likes to cook so i involve hershes very helpful one father with an overweight obese child said the kids have to help with setting the table clearing off the table and other chores difference cleanup approximately 38 of families with an overweightobese child identified frustration with children not helping to clean up after meals compared to 15 of parents with normal weight children one mother with an overweight obese child stated they are supposed to take their dish in there kitchen and scrape it off and put it in the sink and its usually damion that dont want to do it you know he dont want to take his dish and scrape it or he just wants to run ahead of everybody first one throughbut the rest of them follow him and so im stuck with the dishes one father with an overweight obese child said cooking meals makes stuff dirtycleanups never fun but thats true about most things in lifethey kids have to help clean up the mess and they dont like itso they usually dont do it discussion findings from the current study indicate that there were some similarities and some differences regarding how parents with and without an overweightobese child in the household perceived family meals these findings may shed light on potential risk and protective factors of family meals within raciallyethnically and socioeconomically diverse households first findings indicated that parents of normal weight children had family meals because they promoted connection and communication among family members and did not pressure their children to eat food served at family meals compared to parents of overweightobese children these findings may suggest that promoting communication and connection during family meals and using less controlling parent feeding practices creates an atmosphere at family meals that is conducive to family meal enjoyment and healthy eating in children thus potentially leading to child normal weight status previous research supports these current findings by showing associations between a positive emotional atmosphere in the home 24 a positive emotional atmosphere during family meals 1525 less controlling feeding practices 26 27 28 29 30 and child normal weight status second findings indicated that parents of an overweight obese child had family meals because it was tradition tended to use pressuretoeat feeding practices with their children at family meals allowed electronic devices during family meals reported child behavior problems at family meals and reported problems with getting children to help clean up compared to parents of normal weight children these family meallevel characteristics experienced in households with an overweightobese child may be potential risk factors for childhood overweight status for example it may be the case that parents of overweightobese children have family meals because they are supposed to thus communication and family connection may be less likely to occur in such a context additionally having more distractions during meals child behavior problems and parental pressuretoeat feeding practices may create an environment that is less conducive to family enjoyment of the meals overeating and more unhealthy food intake thus potentially leading to child overweightobese status past research supports these current findings by showing associations between electronic devices at meals 31 parent controlling feeding practices 26 27 28 29 30 negative emotional atmosphere at family meals 1525 and child overweightobese status third similarities found between families with and without an overweightobese child such as having family meals in order to feed people to feed children more healthfully and involving children in meal preparation and carrying out family meals suggest that these common factors may give parents buyin regarding family meal interventions for example interventions targeting childhood obesity by family meals should consider emphasizing the importance of feeding childrenfamily members feeding more healthful foods and family meals as a way to involve children in the meal preparation in order to gain buyin from parents for successful intervention delivery this study has both strengths and limitations first the large qualitative sample size provides indepth insight into potential risk and protective factors for family meals by child weight status additionally the large raciallyethnically and socioeconomically diverse sample size increases confidence of these qualitative findings second the study design of prestratifying households by child weight status provided a large sample size to identify important qualitative themes by child weight status third the study was conducted with a raciallyethnically and socioeconomically diverse population one limitation of the study is that the majority of the sample was comprised of singleheaded households thus findings from the current study may not be generalizable to dualheaded households another limitation of the study was that the sample only included families who ate more than three family meals per week it would be important for future research to examine households with a greater variability in the frequency of family meals further it is important to keep in mind that other factors may have influenced the themes found in the study such as culture food insecurity age of child parent weight status and parent education we were unable to control for these factors because of the qualitative design conclusions overall results from the current study suggest that parents from raciallyethnically and socioeconomically diverse households with and without overweightobese children have some similar and some different perspectives regarding family meals findings suggest that the differences regarding family meals in households with overweightobese children may provide insight and potential intervention targets into why overweightobese children may not benefit from the protective nature of family meals compared to normal weight children future research is needed to confirm findings from the current study additionally longitudinal and randomized control trials are needed to identify which family meallevel characteristics are most protective for child weight status author disclosure statement no competing financial interests exist

background several quantitative studies have found a protective association between family meal frequency and child and adolescent weight and weightrelated behaviors eg healthy dietary intake less disordered eating behaviors however limited qualitative research has been conducted to understand more in depth about family meallevel characteristics eg rules responsibilities and interpersonal dynamics that may be risk or protective factors for child weight and weightrelated behaviors the current study aimed to identify family meallevel characteristics within raciallyethnically and socioeconomically diverse households that were similar andor different between households with and without an overweightobese child methods the current study is a qualitative study including 118 parents of children ages 612 who participated in the family meals live study parents 92 female were from raciallyethnically 87 minority and socioeconomically 73 35000 per year diverse households parents were individually interviewed during a home visit data were stratified by child weight status ie normal weight vs overweightobese and analyzed using deductive and inductive content analysis results qualitative results showed some similarities and some differences in family meallevel characteristics by child weight status that may provide insight into past research showing significant associations between family meal frequency and child weight and weightrelated behaviors similar themes between families with and without an overweightobese child included family meals provide more healthful food rules about manners meal planning and involving children in meal preparation themes that were different between families with and without an overweightobese child included connection and communication clean your plate rule electronic devices and child behavior problems conclusions findings from the current study may be useful for developing interventions for raciallyethnically and socioeconomically diverse households with and without an overweightobese child to be delivered through family meals

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introduction selfmanagement support aims to improve health in chronically ill populations sms an essential component of the chronic care model is driving the reform of chronic condition management in north america sms is increasingly embedded in national system and community policy documents on chronic condition management is integrated into communitybased care primary care and healthy aging and is considered part of a public health strategy however sms is largely failing to meet the needs of many disadvantaged populations living with complex needs these populations are less likely to benefit from sms because of low uptake low attendance at clinical appointments and high attrition rates possibly because of low rates of health literacy high rates of multiple diseases and difficulties in access to care some populations have higher prevalence rates for chronic conditions greater difficulties in managing their conditions and worse health care outcomes sms approaches that fail to help these groups may exacerbate inequities an international framework identified key strategies for developing a comprehensive approach to sms and emphasized the need to address health equity concerns in canada few initiatives address sms for underserved populations although the need to address this health equity gap has been identified in national and international settings to this end a group of decision makers who have expertise in providing sms to underserved populations living with chronic conditions and who represent government nongovernment research organizations health authorities aboriginal communities and medical practices were brought together to discuss how they could improve sms for underserved populations the purpose of this study was to facilitate knowledge exchange among these stakeholders to identify priorities and actions for improving sms for underserved populations in british columbia methods numerous methods are available for gathering and organizing data from a group of respondents however we chose concept mapping because concept maps provide a systematic way to organize and rank stakeholders ideas and understand how the ideas relate to each other which is helpful in the development of a strategy we engaged in 3 major conceptmapping activities 1 brainstorming ideas 2 sorting and rating ideas and 3 analyzing and interpreting the concept maps we used a website for the brainstorming activity a facetoface 1day workshop for all 3 activities an online survey and an interactive webinar for analysis and interpretation we used concept systems software version 201332211 to sort and rate ideas a researcher who is a certified concept systems facilitator guided the design and implementation of the conceptmapping process and facilitated the workshop ethics approval was obtained from the behavioral research ethics board at the university of british columbia this study was conducted from august 2013 through june 2014 procedures recruitment a purposeful sampling technique was used to recruit participants who had experience working with diverse underserved populations living with a range of chronic conditions prevalent in these populations eligibility criteria were that participants worked in british columbia and had knowledge and experience in providing sms to underserved populations living with a chronic condition sms was defined as the systems policies services and programs that extend across health care social sectors and communities to support and improve the way people manage their own chronic conditions optimize their health and live well a steering committee recommended potential participants who met the inclusion criteria and invitations to participate in the study were sent by email a total of 26 people participated in 1 or more phases of the study the sample size for each conceptmapping activity was sufficient to meet the statistical requirements for a valid and reliable result most participants worked with several underserved populations that lived with a range of different chronic conditions approximately 70 of participants worked in health authorities and educational institutions and approximately 35 had more than 10 years of experience working in the sms field brainstorming and idea generation participants who agreed to take part in the webbased online brainstorming phase were asked to generate responses to the following question what could be done to improve selfmanagement support for underserved populations living with chronic conditions in british columbia ideas submitted were anonymous but could be viewed by all online participants during 2 weeks 109 ideas were generated ideas were then synthesized by the researchers to remove similar or duplicate ideas seventynine ideas were presented at the facetoface workshop and attendees had an opportunity to review and suggest new ideas not included in the synthesized list an additional 13 unique ideas were added for a final set of 92 ideas structuring the ideas by sorting and rating the 92 ideas were entered into concept systems software the software randomized the ideas to create sorting and rating cards participants were provided with a set of cards and were asked to organize them into groups based on perceived similarity in meaning and to give each group of cards a name that reflected the theme the ideas represented participants were also provided rating worksheets that listed the 92 ideas alongside a 5point likert scale participants were instructed to scan the entire list of ideas and rate each idea on the scale by considering the importance of the idea relative to the other ideas generated and the feasibility of implementing the idea in the next 3 years although a range of criteria could have been used importance and feasibility were proposed by the research team and endorsed by participants because of the perceived relevance of these criteria to current policy and practice environments and their welldocumented use in concept mapping studies for planning purposes preventing chronic disease data analysis and interpretation of the concept maps four sequential activities were used to analyze and interpret the results 1 an initial facetoface workshop to interpret selected maps 2 postworkshop calculation and interpretation of new maps 3 online survey for validation of results and generation of potential implementation actions and 4 interactive webinar discussion to review revised findings and survey results and to generate ideas for developing a strategy facetoface workshop the sorting and rating data were analyzed by using concept mapping software which uses multidimensional scaling analysis and hierarchical cluster analysis to depict relationships between ideas create clusters and generate concept maps the first map generated a point cluster map showed a visual arrangement of the 92 ideas plotted on an xy graph the closer the points were to each other the more often participants sorted ideas together a stress value which reflects how often the ideas were sorted together was calculated as 034 which is an acceptable value because it falls between the ideal range of 028 and 039 we then used the software to create cluster maps that displayed the ideas as 2dimensional polygons on the basis of how conceptually similar or dissimilar the ideas were to each other the distance between the ideas rather than the exact location of the ideas on the map illustrates the degree of similarity between ideas the software generated numerous cluster maps each of which displayed a different number of clusters recognizing that we would have to follow the recommended process for cluster selection after the workshop we shared a 10cluster solution with participants because we felt this provided a reasonable number of clusters to generate preliminary discussion working in small groups participants reviewed how the ideas were grouped and then reviewed the cluster names to see if they represented the dominant themes for each set of ideas during this process participants struggled to find a common theme among the ideas in each cluster they felt that a 10cluster solution was not likely the best solution for developing an sms strategy and that many of the softwaregenerated cluster names did not reflect the major ideas expressed in each group participants recommended that further cluster analysis be conducted and cluster names reviewed figure 1 go zone map for the cluster fostering partnership shows the average importance and feasibility rating data for the ideas included in this cluster the right upper quadrant represents the ideas that were rated above average on both importance and feasibility postworkshop analysis in a postworkshop analysis the research team worked to find a cluster solution in which the ideas in each cluster were cohesive and represented a common theme the concept mapping software program filter was used to eliminate spurious relationships between ideas and to reduce the noise in the data to provide groupings with stronger conceptual coherence we applied a filter to the data to create cluster solutions based on statements sorted together by 3 or more participants we systematically examined the ideas that merged together as clusters were reduced from 23 to 7 we used quantitative data specifically the bridging values of cluster solutions that were computed by the software program the bridging value of a cluster was the average bridging value for each statement in the cluster clusters with low values were usually more cohesive and easier to understand a bridging value for a statement was a measure of whether it was sorted with others that were close to it on the map we also used qualitative processes to interpret whether the ideas in the clusters formed coherent conceptual themes as we moved across each cluster solution participants agreed on 11 clusters representing strategic directions we calculated the go zone for each cluster to show the bivariate plot of the average importance and feasibility rating data for each idea preventing chronic disease online survey participants were invited to respond to an online survey that asked them to review the 11 cluster names and indicate their agreement if there was no agreement participants had the opportunity to provide comments and suggest alternative names agreement was 71 to 83 for 10 of 11 cluster names among the 17 respondents participants were also invited to provide suggestions on how to implement the 40 ideas that were rated highly important and feasible facilitated interactive webinar discussion the research team held an online webinar discussion with 9 participants to review the maps describing the 11cluster solution and the online survey results final decisions were made on cluster names prioritization of clusters and the conceptual grouping of clusters results postworkshop analysis participants agreed that the 11cluster solution provided a meaningful foundation for identifying strategies the 11 clusters were foster partnerships shift government policy promote integrated care reform enhance health care provider training increase community education enable client engagement support community development incorporate client support systems recognize client capacity develop client skills training and tools and tailor sms programs on the basis of the positioning of the clusters on the gozone maps it was decided that the cluster strategies should be considered at 3 interrelated levels 1 system 2 community and 3 individual we organized the 11 clusters in relation to the levels identified participants considered the foster partnerships cluster the foundation for the other 3 groups because partnerships were inherent in many of the ideas in the other clusters this conceptual structure formed the foundation for the sms strategy for underserved populations the collective results of the gozone maps for each cluster showed that 40 of the 92 ideas were located in the upper right quadrants and represented the ideas that had aboveaverage ratings for importance and feasibility participants agreed that these 40 ideas should form the recommended actions in the strategy the resulting strategy comprised the 11clusters and 40 recommended actions for improving sms for underserved populations in british columbia discussion twentysix stakeholders from policy practice and research sectors identified a strategy with 11 strategic directions and 40 recommended actions that address the question of what could be done to improve sms for underserved populations living with chronic conditions in british columbia results showed that efforts need to be directed at 3 interrelated levels 1 system 2 community and 3 individual this understanding aligns with a systemsoriented approach to public health and with the knowledge that initiatives interacting across multiple sectors are required to improve health outcomes for underserved populations the strategy does not provide details on how to implement the strategic directions and recommended actions the development of implementation plans requires further local and contextspecific conversations with underserved populations living in different regions on how best to advance the strategic directions and recommended actions the sms strategy can address health inequities in sms and chronic condition outcomes in underserved populations in numerous ways first it targets populations that have greater inequities such as racialethnic minorities immigrants refugees lowincome adults older adults homeless people rural residents and aboriginal populations second the strategy contains recommended actions to help change government policies that create inequities in chronic conditions in underserved populations third the partnership framework promotes collaborations between governments health authorities health care organiza tions and community agencies that could increase the number and range of smsrelated initiatives for underserved groups by sharing and leveraging skills capacities and resources finally the key strategies on enhancing health care professional training on issues specific to sms in underserved populations engaging underserved populations in identifying barriers and generating solutions and gearing sms programs to client capacity all work toward increasing more effective implementation and better health outcomes for underserved populations living with chronic conditions preventing chronic disease concept mapping was a good technique to develop a strategic plan because of the participatory process which enabled stakeholders working at different levels in the system to have equal opportunity to propose ideas it enabled decision makers to participate directly in research to generate knowledge relevant to their work domains and provided a relatively quick way to generate a plan among participants in different geographical locations because concept mapping uses a range of data collection methods and different types of analysis we were able to incorporate the benefits of each form of engagement with a mixedmethod approach to address a complex topic efficiently during a relatively short time the findings of our study represent the opinions of a few stakeholders working in british columbia and it is likely that some perspectives were not captured in the concept mapping process nor reflected in the final strategy members of underserved communities living with chronic conditions were not included because of concerns about harms that might result from engaging in concept mapping without adequate training a decision was made to engage consumers in future discussions of the strategy through participants organizations although we had participants from nongovernment organizations serving the health and social needs of underserved populations and aboriginal communities most attendees represented organizations centered on health care rather than social services which may have also influenced the findings the sms strategy for underserved populations represents the ideas of policy practice and research stakeholders working in british columbia but the priorities and recommended actions align with sms and health equity developments in other provinces in canada as well as in the united states australia and the united kingdom as such the sms strategy may be relevant to regions outside british columbia the strategy can be used to stimulate further public health dialogue on sms in underserved populations and as a roadmap for decision makers to help guide the development of initiatives that work toward reducing chronic condition management inequities in these groups targeted chronic disease prevention and management approaches for diverse and vulnerable populations in alberta calgary alberta health services 2012 accessed december 1 2014 tables table 1 partner with agencies that have a successful track record of outreach to underserved populations to ensure that they know about prioritize and are able to participate in sms programs 18 deliver communitybased chronic disease management programs that provide sms in partnership with community organizations 28 28 preventing chronic disease shift government policy involve underserved populations in decision making on sms initiatives with the british columbia ministry of health and health authorities 8 advocate for politicians to implement policies to provide more social infrastructure and financial support for underserved populations to address issues of income inequality and income disparity 12 promote integrated care reform promote interprofessional collaboration and integrated care to manage the complexity of chronic disease management and to provide sms 46 develop collaboration with educational institutions and embed sms in their curriculum 91 create a full communitybased primary health care system that incorporates a full sms model and social determinants of health with a focus in triple aim 83 create processes that make transitioning both in and out of service easier and barrierfree 37 involve the health care system and wider community in the expanded chronic disease models to provide the resources and infrastructure to enable sms in underserved populations 77 create an integrated systemwide approach to chronic disease management that includes sms as one of its mandates 61 enhance health care provider training provide health careprovider training in health literacy cultural competency and safety to ensure sms initiatives are client friendly culturally appropriate language specific and tailored to the literacy level and readiness of client 27 ensure sms is a routine part of regular office visits for chronic disease management 3 focus services on wellness as well as illness management 13 train provide accessible venues for groups of individuals with similar chronic conditions to meet and provide support to each other 2 provide coaching to support people in their wellness 56 train health coaches to provide ongoing support to help clients manage their disease navigate the health care system and access resources 49 recognize client capacity develop sms that takes into account varying literacy and health literacy skills in underserved populations 67 use translators that are linguistically and culturally aligned with clients 74 build on the personal agency of clients given for example their language or literacy skills offer clients skills training to effectively selfmanage 16 consider differences within underserved populations when sms facilitators are implementing programs 6 develop teaching and learning models for clients to develop skills to effectively engage with health professionals in shared decision making 21 ensure selfreflection tools in sms to ensure measurements are in place for progress 86 tailor sms programs when creating sms programs for physical conditions include content on mental health issues 10 use a holistic approach to sms initiatives that considers physical cultural lifestyle and spiritual needs of underserved populations 52 develop materials and programs for health literacy that can be used by health care professionals 5 abbreviation sms selfmanagement support a the numbers in brackets represent the original number of the ideas presented in figure 2 preventing chronic disease author information corresponding author susan l mills preventing chronic disease

selfmanagement support sms is an essential component of public health approaches to chronic conditions given increasing concerns about health equity the needs of diverse populations must be considered this study examined potential solutions for addressing the gaps in selfmanagement support initiatives for underserved populationsstakeholders representing government nongovernment organizations aboriginal communities health authorities medical practices and research institutions generated sorted and rated ideas on what could be done to improve selfmanagement support for underserved populations concept mapping was used to facilitate the collection and organization of the data and to generate conceptual mapsparticipants generated 92 ideas that were sorted into 11 clusters foster partnerships promote integrated community care enhance health care provider training shift government policy support community development increase community education enable client engagement incorporate client support systems recognize client capacity tailor selfmanagement support programs and develop client skills training and tools and grouped into system community and individual levels within a partnership frameworkthe strategy can stimulate public health dialogue and be a roadmap for developing sms initiatives it has the potential to address sms and chronic condition inequities in underserved populations in several ways 1 by targeting populations that have greater inequities 2 by advocating for shifts in government policies that create and perpetuate inequities 3 by promoting partnerships that may increase the number of sms initiatives for underserved groups and 4 by promoting training and engagement that increase the relevance uptake and overall effectiveness of sms

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in this paper we explore the intractable problem of ethnic inequalities in severe mental illness and care experiences and the common explanations we consider the barriers to progressive and cohesive action in both society and in professional practice and propose ways of overcoming these inadequate research methods that fail to interrogate experience alongside survey or administrative data have contributed to a lack of compassion about what is at stake for those who experience severe mental illness and inequalities we explore how societal processes including racism cannot be separated from the question of how to reduce ethnic and social inequalities and multiple disadvantages dominant and yet divergent professional narratives and failure to learn lessons and build on past experiences are products of social and psychological defences against the pain of noticing injustices individual and group political ideologies and power relationships are then enacted to sustain inequalities leadership and commitment to bring together hidden patient voices with divergent professional narratives and more precise research are needed to improve the health literacy on the evidence and motivate interventions ethnicity and health inequalities members of some ethnic minority groups experience an increased risk of a first diagnosis of severe mental illnesses especially psychoses people in all ethnic minority groupsbut most notably black caribbean black african and black british peoplewith a diagnosis of severe mental illness experience higher rates of contact with the police and criminal justice system more admission to psychiatric hospitals less voluntary inpatient care and less primary care intervention 1 2 3 4 greater levels of criminal justice system involvement for black caribbean and black african patients do not reflect reported violence or levels of substance misuse nor delays in access to firstepisode services 56 compared with other ethnic groups black caribbean men and women are more often referred to specialist mental health services when recognised to have a mental health problem by their general practitioner rather than being treated in primary care 1 some other subgroups are notably at a higher risk of compulsory treatment women older people those experiencing social isolation those lacking an advocate or general practitioner involvement and those facing multiple service contacts 2 7 8 9 10 these trends may signal wider issues of disempowerment lack of trust social exclusion and a lack of political influence evident most in ethnic minority groups but common in other patient groups who complain of exclusion and dissatisfaction with care these complaints are heard in local patient groups and are rarely captured in the research or professionalised evidence there is significantly more use of the mental health act for some ethnic minority groups despite decades of investment in considering least restrictive options and alternative healthcare provisions 11 use of the mha varies by providers and is higher in urban areas with increased area deprivation and ethnic density mha use is especially high for black caribbean black african and black british patients in the uk 1213 aside from the commonsense notion that people would favour the least coercive and most empowering pathways to care that maximise autonomy there are financial arguments for less use of the mha and reducing tackling inequalities in the use of the mha the greater use of the mha necessitates more use of inpatient beds growth in legislative safeguards like tribunals and more need for advocacy and quality standards in assessment and treatment processes these additional demands have not been adequately included in cost models so reflecting the greater risk of compulsory treatment and the additional incurred costs in a study in london the cost of inpatient care for black patients was 24 times that predicted based on population numbers if the spending for black patients was the same as the average across all groups in london £762 million savings could be realised 14 this report also indicated twice as much spending on black patients compared with white patients on community services if service use were the same for black and white patients a further £238 million would have been available for investment what explains inequality experiences why should ethnic groups require more care through community inpatient forensic and criminal justice services or by mha use socioeconomic factors are likely to play a role in the increased risk of diagnosis of mental illness found for some ethnic minority groups however although poverty and social factors are often proffered to explain disparities in the use of care services and the mha it is important to note that adjusting for social factors does not fully explain the higher use of care services or rates of compulsory assessment and treatment in some ethnic minority groups 15 other factors are thus likely to be important furthermore the statistical method of treating such factors as confounders obscures the ways in which social and economic risks are shaped by the ways in which ethnic identities are understood and acted onmeaning that within these statistical models we will be removing important closely associated influences this procedure reflects a poor understanding that ethnicity as a variable reflects a complex set of historical and contemporary processes and disadvantages and is not only an individually embodied and discrete category of person people do not live as adjusted versions of themselves and one might question whether social adversity linked to race and ethnicity is in fact fundamental to the construction and experience of ethnicity including the experiences in health systems for example social adversity including discriminatory events and traumas acts as the exposure and then also shapes these effects as well as emotional and behavioural responses which can constrain the exercise of protest and expressions of power 1617 for example the american psychiatric associations recent statement on racism and mental illness suggests that traumatic interactions can result in poorer selfesteem and internalised hatred reflecting how adversity can undermine resilience and the ability to protest and protect 18 cultural explanations sometimes explanations for differences in treatment are related to ethnic differences in beliefs expectations and attitudes to mental illness or to the nature of the illness which may deter helpseeking 19 in addition the way services are constructed organised and run can systematically favour those who more closely fit these structures and processes those who are familiar with how services operate and where professionals and patients share an understanding of the role of specialist mental healthcare dynamic interactions between patientprofessional and patienthealth system take place in spaces in which systematic inequalities may emerge with no ill intent or obvious failings in practised standards of care 2 yet to understand this we need a richer empirical evidence base built on patient experiences to inform appropriate responses and accommodate the needs and priorities across diverse patient groups some patients present with unusual symptoms that include culturally shaped health beliefs or idioms of distress that may be misunderstood as being a physical disorder if the metaphors used are of bodily functions alternatively symptoms may be judged to be delusional beliefs if they seem to invoke supernatural forces or witchcraft also explanatory models of distress may suggest to the clinician that difficult social and relationship strains should be the foci for remedy rather than mental distress being privileged for priority intervention there are also differing thresholds for the willingness to express psychological distress across cultures 20 21 22 in some instances there is underrecognition of mental illnesses for example in personality disorders 22 when other interventions may be considered more appropriate such as housing or social care or substance misuse services these are certainly helpful but the underlying distress or mental illness may not be identified precisely enough and thus interventions may not be offered cultural beliefs about illness or explanatory models for the experience of illness around causes consequences and expectations of treatmentheld by both the patient and the clinicianwill determine the motivation for and types of helpseeking behaviours these influence the clinicians impression about diagnosis and appropriate treatment although the clinicians own cultural experiences and ways of relating to cultural and ethnic groups and their own ethnic identity will invariably influence what is noticed and what is overlooked 23 systemic and structural influences various analyses over the years suggest that patients of black caribbean black british or black african heritage experience a pattern of adverse pathways to care 124 these findings have been sustained for over 30 years and more recent evidence suggests that similar inequalities might exist for patients in other ethnic minority groups despite the long period over which these inequalities have been documented we have not seen effective actions or sufficient motivation to tackle them although there have been periods of public health and national health service action these were time limited and insufficiently resourced or engaging given the intractability of the problems with no visible or sustained shift in ethnic variations in pathways to care 25 although interventions to improve care pathways are proposed 2627 there is little evidence that these are more widely adopted or implemented or that these are being refined and evaluated nationally and regionally how can we explain these variations explanations for inequalities are likely to lie in trajectories starting with earlylife experiences school exclusions a lack of educational opportunities and achievement and a lack of sustainable employment some identity groups are excluded and disempowered leading to social defeat and demoralisation and some earlylife social networks operate through fears threats and domination leading to crime 28 language matters do we use the language of health inequalities and disparities or of racism and discrimination perhaps this is a false dilemma as structural inequalities lead to discriminatory outcomes irrespective of whether discrimination is individually felt or noticed however the idioms in which these inequalities are explained and tackled either engage or disengage people across or within patient movements professional disciplines and commissioning and policy circles language can be motivating if it resonates with experience but it can be demotivating or produce opposition if it is perceived as dispiriting or attacking of ideologies and in that instance it can therefore perpetuate inequalities some agreement is needed on the vocabulary for any shared and cohesive effort racism prejudice and discrimination are frequently invoked to explain ethnic inequalities in health social and economic outcomes a systemic analysis is needed of how racism works in society and in organisations racism prejudice and discrimination can take many forms and are more openly expressed at times of austerity and political extremism 2930 there is growing evidence showing the relationship between experiences of racism and discrimination and the risks of mental illness 31 32 33 however there is little empirical evidence that individuallevel conscious and prejudicial attitudes of clinicians act to disadvantage specific groups 2 at least the complaints and reports of blatant behaviours and attitudes are unusual given the greater emphasis on equalities policies and the growth of educational and developmental programmes at the same time the latest surveys of national health service care show that bullying harassment and discrimination are not uncommon experiences in our workforce and that senior staff and board representation is not commensurate with population demographics on ethnicity and race 34 health professionals do need to hear views about discrimination gender disadvantage racism and all varieties of prejudice and respond constructively patients who feel disbelieved where suffering is not understood or accepted are unlikely to be at ease or willing to open up in conversation this dynamic between the patient and professional is not likely to foster trust or the foundations for an alliance with balanced and respectful negotiations around treatment expectations 35 dismissing discrimination in general and specifically racism as a subjective attribution not verifiable by objective measures fails to recognise the degree of distress that racism engenders or the physiological and health effects of the experience of discrimination denial and nonrecognition are important elements of the psychodynamic of racism and enactments of prejudice 36 the reality is that racism is not obvious nor easily detected in everyday life and a fear of persistent racism in society has an effect on health even in the absence of direct violence interpersonal behaviours and communications may be seemingly innocuous yet can signal prejudicial attitudes a lack of trust fear or avoidance these microaggressions can lead to poor health and the effect can be felt by ethnic minorities but are also felt by women experiencing disadvantage from any professional group 37 38 39 methods for assessing microaggressions are still being developed yet their observation in practice needs only vigilance and a willingness to notice and discuss their intrusion into interpersonal and institutional life structural and organisational racism reflect broader conditions in which all varieties of racism thrive beliefs and fears about racism act as a mechanism by which coping responses are thwarted and only unhealthy coping is possible through either flightorfight reactions or anger which are harmful for health new paradigms the explanations for disparities in pathways to care warrant inspection and critique so that we can progress to evidenced solutions to these longstanding and apparently intractable complex and forever changing issues also called wicked problems 2440 the wider community health and social systems which reliably and predictably continue to generate institutional inequalities need to be better investigated and targeted for intervention a challenge for all is that data have shown no change in patterns 74142 indeed that was the reason the count me in census was ended as no improvements were seen 43 when perceived to be competing over scarce resources at a time of austerity the rise of extremism and prejudice in the uk usa and europe may cause additional distress it is regrettable is that we repeatedly fall foul of these privileged psychological and political processes that contaminate group thinking and leadership and promote specific types of political discourse that support economic exploitation which means we end up manufacturing discriminatory policy attempts to remedy inequality and discrimination are then vilified and hampered by limited resources lesser allocated priority and even assertions that tackling discrimination or inequality is undermining the social fabric of a race neutral or culturally blind society the indelible effects of racism historical injustices and deprivation are not invisible to people affected by such experiences this invariably leads those subjected to inequalities to express outrage and yet also perplexity at the silence one response to this is that official policy language changes to silence mention of race and racism as if a change of vocabulary alone removes underlying injustice and structural disadvantage at some point there is an awakening or an incident and the search for the causes of health and societal inequalities reappears one could argue that the prime ministers race audit is an example of a sudden awakening after a period of silence in the context of rising extremism discrimination and growing inequalities we anticipate a more thoughtful and progressive response for any future actions is needed rather than a reassertion of silence clinical social and political leaders must be cognisant of these repeated historical and yet also contemporary patterns of responding to race relations 45 46 47 the lack of recent data works against an overarching commitment to tackle inequality or monitor progress of efforts this loss of visibility and silencing is compounded by data that neglect the role of new and emerging ethnicities and identity groups there is much hybridity of identities through which people experience the world and relate to others in such a constructionist paradigm we risk that ethnic inequality in pathways to psychiatric care is overlooked or neglected for fear that ethnic categories are too broad to understand causes of inequality and effect change this can be most challenging when distress or inequality is felt through links to a deeper and more specific set of identities rather than the race or ethnic label that is adopted in official statistics this tension is also in flux and different latent identity characteristics are activated at times of adversity or conflict or when coordinating protest the recent acronyms of bme and bame do nothing but classify large groups of people into categories that can never work for all people falling in those categoriesjust as racebased categories do not work in all circumstances neither will ethnicity ethnic categories are devised and applied usually by those in positions of power when there is a need for group data cultural categories are actually complex simplifications of collective and individual identities related systems of shared beliefs kinship systems and implicit behaviours producing a consistent framework that tackles the macro or structural factors as well as the interpersonal and felt experience is challenging because the level of resolution or precision is invariably less when one level of analysis or felt experience is applied to the other there is disagreement about how to transform health systems that generate race or ethnic inequalities without implicating individual interpersonal behaviours and prejudicial attitudes the causes of inequalities are unlikely to be related to only a single protected characteristic such as race gender religion age disability or even nonprotected characteristics such as poverty unemployment or class prejudices operate across these categories and can be felt in unexpected ways 48 inequality emerges because of combinations and clusters or intersectional sources of exclusion disempowerment and sustained and deepening disadvantages that operate through and are sustained by power relationships 49 50 51 52 the wider influence of area deprivation low income in families and impoverished localities all produce poor health outcomes in turn these influences in urban environments can undermine mental health in combination individual or structural violence and discrimination lead to more traumatised and less confident informed resourceful and resilient communities the combination of these factors with impoverished and unresponsive public services have wider significance given the recent enquiries into how poverty and systems of failure appear to particularly impinge on the poorer socially excluded minority migrant and voiceless sections of society for example when considering grenfell or other public scandals the sense of disempowerment at a structural and organisational level permitting wealth and affluence to exist alongside dickensian and neglectful public practice is extraordinary a minority experience is overlooked and left for those less fortunate to resolve through their own creative and desperate devices rather than through politically engaged optimistic and publicly supported enactment of citizenship rights and responsibilities this is not to say that promoting the capabilities of those facing disadvantage is not important and essential but structural disadvantage unless tackled will limit agency and capabilities the future this brief analysis shows that health inequality by ethnic group remains a real and ostensibly intractable challenge professional opinions are divergent and coherence across sectors from policy commissioning management and clinical care is elusive in part this is because of the notion of race and race inequality immediately evoke latent notions of racismrelated violence and hostility failed science and impasse and discomfort among those trying to search for words to relate to another less familiar cultural group we fail to note the historical lessons nor accept that inequalities can be generated by and further compound social disadvantage and poor health sustained inequalities lead to a lack of trust in public authorities and engender disempowered and pessimistic thinking the synergi collaborative centre is an independent centre of excellence that aims to marshal multiple forms of the research evidence and curate it alongside the views of patients and the public to ensure that professional discourse is centred on what is at stake for them we argue that disagreement dispute and dissent reflect unseen and unheard perspectives and we propose to not privilege the voices of larger organisations or familiar experts and instead gather lived experiences and hear hidden voices which we argue hold clues for how health inequalities arise and are sustained how racism operates and how we can empower people and communities to make best use of the cultural affordances and community assets at their disposal motivating and engaging the powerful to act and in directions that the powerless can be enriched and so the powerful give up their authority is not a popular or wellrehearsed approach this process is essential in health systems interventions and leaders need to operate with a collaborative mindset of sharing power we propose that there is a failure of professional literacy and communications around race not least because of its contentious historical legacy but that this must not enslave future generations we should be aware of the historical legacies that operate in the presence and structure of power relations but we should also act to understand and reduce structural sources of inequality that set the context in which interpersonal enactments of inequality a democratic mature and equal society should actively tackle hostility and violence and at the same time acknowledge and restrain microaggressions and the silence around injustices we are seeking ways of nurturing sustainable health systems that demonstrate collaborative leadership and greater importance attached to patient and public voices including concerns about racism and we need greater professional skills in emotionally intelligent and collaborative leadership and communication linked to race and ethnic inequalities in society and clinical settings this approach is an important component of cultural competence cultural competence is not a finite collation of testable knowledge rather it is a skill set that take time to master and requires developmental experiences that improve engagement with narratives of patients sitting alongside evidencebased medicine and healthcare conclusions it is time to examine the multiple often competing valueladen narratives of what causes inequalities exotic cultural idioms and explanatory models service construction and delivery and deprivation racism and discrimination we need to contrast the ways in which all of these can be conceptualised by personal individual family or cultural group and organisational and structural agents of causation it is right that we learn from the stories of patients in general and ethnic minority patients as these offer insights into how care systems fail thus transcending the traditional but not unchallenged hierarchy of evidence commonly associated with the medical discipline the choice of methods should relate to our research questions and what we seek to explore the gold standard of randomised controlled trials cannot in isolation by its design features capture mechanisms or the richer and more indepth patient stories to inform processes of service delivery and public health promotion 5354 this new form of science requires that we attend to the preverbal the visual the emotional and the less graspable aspects of ethnic inequalities and severe mental illness and yet be prepared to provide a progressive and response set of options and conditions that match and overcome the inevitable resistances and antigroups that align against such tenets

in this paper we explore ethnic inequalities in severe mental illness and care experiences we consider the barriers to progressive and cohesive action and propose ways of overcoming these clinical and policy leadership must bring together hidden patient voices divergent professional narratives and quality research

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introduction obesity negatively affects human health by directly affecting psychosocial wellbeing and by increasing the likelihood of various other diseases once viewed as a predominantly western problem obesity has also emerged as a serious public health problem in many lowerand middleincome countries the increasing prevalence of obesity in these contexts is broadly driven by socioeconomic development which in turn promotes obesogenic dietary and activity behaviors consequently there is a substantial body of research focused on the association between socioeconomic status 6 and obesity sobal and stunkard published the first major review of studies reporting associations between ses and obesity their review highlighted the importance of social research in explaining the global rise in obesity prevalence and provided compelling evidence that the burden of obesity in higherincome countries was disproportionately placed on the poor particularly among women conversely their review found that obesity was largely a problem associated with affluence for both men and women in lowerincome countries however evidence soon emerged from brazil that suggested that the burden of obesity was shifting toward lower ses strata this inverse sesobesity relationship has now been observed in a variety of lowerand middleincome contexts furthermore evidence suggests that this shift progresses as a function of economic development and urbanization an important gap in this literature is that most previous studies have focused on single indicators of ses such as education or income or composite scores that combined multiple indicators however some studies have found contrasting effects of individual ses indicators such as income and education consequently our interpretation of the relationship between ses and obesity in a particular context may be influenced by the ses indicator investigated thus understanding the concurrent effects of multiple ses indicators could yield important etiological insights our primary goal was to help address this gap by investigating crosssectional associations between obesity and multiple indicators of ses in a birth cohort of young adults enrolled in the cebu longitudinal health and nutrition survey we also tested the hypothesis that the sesobesity gradient would vary as a function of urban development at the intraregional level using a continuous scale measure that captures urban heterogeneity within a contiguous area this contrasts with and complements previous studies that have examined differences in the sesobesity relationship across different levels of economic development either by comparing countries or distinct geographical regions within countries materials and methods study design and sample data are from the clhns a communitybased study of a 1y birth cohort living in metropolitan cebu philippines the study area includes 270 administratively defined communities called barangays comprising a 720km 2 contiguous area a singlestage cluster sampling procedure was used to randomly select 33 barangays and pregnant women residing in these barangays were recruited for the study in 1982 and 1983 those who gave birth between may 1 1983 andapril 30 1984 were included in the sample more than 95 of identified women agreed to participate a baseline interview was conducted among 3327 women during mo 6 or 7 of pregnancy another survey took place immediately after birth there were 3080 nontwin live births in the clhns birth cohort subsequent surveys were conducted bimonthly to age 2 y then in 1991 1994 1998 2002 and 2005 the clhns protocols were reviewed and approved by the institutional review board of the university of north carolina at chapel hill we used 2005 birth cohort data when the study participants were young adults women pregnant in 2005 were excluded anyone with missing data on variables of interest were also dropped resulting in a final sample of 987 males and 819 females the analysis sample of 1806 males and females is 59 of the original 3080 single live births recruited for the study this is overwhelmingly due to the loss to followup characteristic of longitudinal studies of this length the 1806 individuals included in this analysis sample did not differ at baseline from the 1274 single live births also recruited at baseline in mean household income and assets or maternal education bmi and height however the analysis sample did have slightly higher birth weights difference 006 kg and lengths difference 018 cm the gender distribution was also different in 2005 than at baseline measures body size measures were collected by trained field staff during inhome interviews using techniques described in lohman et al weight was measured with a mechanical scale to the nearest kilogram while height was measured with a folding stadiometer to the nearest tenth of a centimeter bmi was calculated as weight divided by height squared waist circumference was measured in cm at the midpoint between the bottom of the ribs and the top of the iliac crest bmi is a measure of weight adjusted for height although bmi does not describe fat distribution or differentiate fat mass from lean body mass it is a reasonably good predictor of overall body fat wc is a measure of centrally distributed adipose tissue which is thought to be particularly relevant for a number of disease outcomes based on these 2 measures we dichotomously defined overweight as bmi 25 kgm 2 and central adiposity as a wc 85 cm for males and a wc 80 cm for females though these cutpoints are fairly low evidence suggests that risk of cardiovascular disease outcomes rises at lower levels of fatness in asian than in caucasian populations inhome interviews were used to assess weekly household income measured in philippines pesos and deflated to 1983 values housing quality and assets indicators were used to create a continuous measure of household assets derived from a principal components analysis education based on the highest grade completed by the study participant was categorized using indicator variables as no schooling or any primary school attended any secondary school and attended any college marital status was determined by asking participants whether they were living with a spouse or partner we used 1 communitylevel variable urbanicity which refers to the urban nature of a barangay while most researchers use the urbanrural dichotomy to describe urbanicity we used a continuous measure that captures a range of variation in urbanicity across a single dimension briefly the scale is made up of 7 components derived from data collected for the clhns barangay level surveys population size population density communications transportation markets educational facilities and health services theoretically the scale represents an underlying latent construct labeled urbanicity that is imperfectly reflected in each of these 7 components and could be viewed as a localized proxy for economic development statistical methods due to the design of the clhns individuals are clustered by barangay of residence because social and built environments influence obesity risk we expect individuals living in the same barangay to be more similar to each other with respect to obesity outcomes than they are to individuals living in other barangays this dependence was confirmed in a preliminary analysis for which we used empty randomintercept logistic regression models to estimate the intraclass correlations for overweight and central adiposity in our sample the icc represent the proportion of variation in the outcomes described at the barangay level and thus the degree of dependence in the males the estimated icc for overweight and central adiposity were 018 and 010 respectively for females the respective estimated icc were 005 and 018 ignoring this statistical dependence could result in biased ci around parameter estimates additionally the participants we analyzed started the study living in 33 barangays but now reside in 161 barangays due to the 26 of this sample that has migrated within the study area between birth and young adulthood the result is a heavily unbalanced dataset for which most barangays included in the analysis have fewer than 3 observations to account for these issues we employed generalized estimating equations with an exchangeable correlation structure gee is a method used to analyze clustered data particularly when the dependent variable is binary like more commonly used multilevel models gee return more appropriate se when data are clustered however gee may return more reliable estimates when there are many small clusters using gee we estimated the crosssectional populationaveraged effects of the independent variables measured at both the individual and community levels we began by estimating a series of genderstratified models to estimate the unadjusted effect of each individuallevel ses variable and communitylevel urbanicity on overweight or central adiposity thus placing our research in the context of previous studies that investigated a single measure of ses nonlinearities in continuous variables were tested using quadratic terms and retained in the models when p 005 we then estimated multivariable models that included all 4 individuallevel ses variables and communitylevel urbanicity we tested for multiplicative interactions among these variables which were retained in the models when their respective wald test p was 010 all continuous variables were mean centered but left unstandardized to facilitate gender comparisons all reported pvalues are 2sided the 95 ci for any reported proportions were calculated using the wilson procedure all statistical analyses were conducted using stata version 100 results sample characteristics are reported in table 1 overall the sample was young and lean overweight and or central adiposity were found in 11 of the total sample compared with the 221 of the total sample classified as underweight the distribution of income and assets were similar for males and females although females were more likely to be college educated and married than males the patterns of associations among variables varied by gender but were similar when comparing outcome measures within gender so we focused on describing the overweight results the results for males were similar to those in populations in other lower middleincome countries each of the ses indicators as well as communitylevel urbanicity was positively related to overweight in the unadjusted models in the multivariable model only assets marital status and college education remained strong predictors of overweight the relationship between assets and odds of overweight was particularly strong a 1 sd increase over the mean assets score was associated with a 64 increase in the odds of overweight odds ratio 164 unlike the males marital status was the only crude predictor of overweight in the females though there was no discernable relationship between education and overweight in females or 082 it was notably the only ses indicator with a point estimate that suggested an inverse relationship an inhibitive interaction between urbanicity and assets emerged in the multivariable model for females this could be interpreted as a reduction in the positive effect of assets on overweight as urbanicity increases or viseversa the difference in the estimated effect of assets on the odds of overweight at the ends of the observed urbanicity distribution was considerable at the lowest observed level of urbanicity a onepoint increase in assets was associated with a 29 increase in the odds of overweight or 129 at the highest observed level of urbanicity the same increase in assets was conversely associated with a 8 reduction in the odds of overweight or 092 the ratio of these or was 140 we also explored the nature of this interaction by evaluating the prevalence of overweight in groups crudely defined by tertiles of assets and urbanicity within the lower 2 tertiles of urbanicity there was no clear relationship between assets and the prevalence of overweight however among women living in the most urban areas there was an emerging trend for which the prevalence of overweight declined with increasing assets the lowest prevalence of overweight in the entire sample was for highly urban women with high assets scores discussion we observed a pattern of relationships between ses and overweight and central adiposity that is consistent with studies from other countries with similar levels of economic development assets income and college education were all crude positive predictors of overweight and central adiposity in males from our study in the final multivariable model assets were the most important predictor overshadowing the estimated impact of income this is probably because the assets score which is derived from a principle components analysis of interviewerobserved indicators of assets and housing quality was a more valid andor reliable measure of wealth than income which is based on respondent reports of multiple sources of household income the estimated effect of college education was attenuated in the multivariable model but still positively related to overweight and central adiposity conversely in the females only marital status was a strong predictor of overweight and central adiposity however the multivariable models revealed an important interaction between assets and urbanicity among the most rural women assets were positively related to overweight or central adiposity whereas in the more urban areas assets were not related to overweight or central adiposity this interaction highlights the importance of investigating more carefully the extent of interactions between characteristics of individuals assetsses and the features of places urbanicity associated with varying health risks studies of the relationship between ses and obesity are beginning to produce important insights into rising obesity prevalence in lowerand middleincome countries this body of research initially focused on socioeconomic disparities in obesity in higherincome countries ses tends to be inversely related to obesity particularly among females conversely in lowerincome counties it was once thought that obesity was only a problem for the affluent however a growing body of evidence suggests that the sesobesity gradient is inversely shifting becoming more like that in highincome countries furthermore this shift seems to be occurring in women first and as a function of economic development the early focus on socioeconomic disparities in obesity was reinforced by the fact that most previous studies investigated single indicators of ses such as education or income or composite scores that combined multiple indicators this implies a unitary view whereby ses is treated as an underlying construct that is similarly reflected in multiple largely interchangeable measures however other research has indicated that individual indicators of ses may have varied or even antagonistic effects on obesity a lack of studies considering the independent effects of multiple ses indicators was a key gap that we aimed to address our results were consistent with studies that have examined the independent effects of multiple indicators of ses particularly income and education in lowerand middleincome countries for example a study of brazilian adults living in 2 regions of the country that differed in level of economic development found that the estimated effects of income and education varied as a function of both gender and region of residence income was a positive predictor of obesity in males living in both regions whereas education was inversely associated with obesity in the more developed region for females income was positively related to obesity only in the lessdeveloped region whereas education was inversely related to obesity in both regions given these observations from brazil it is notable that in our study college education in females was the only ses indicator whose point estimate suggested an inverse relationship similar gender differences with regard to education have been recently reported in asian populations in thailand and korea furthermore the interaction between assets and urbanicity in females also mimics the pattern seen in both brazil and when comparing across countries for which ses tends to be positively related to obesity in lowerincome contexts and inversely associated with obesity in higherincome environments to our knowledge our study is the first time this pattern has been illustrated within a single contiguous study area lastly our research has helped confirm that the relationship between ses and body size is much more complicated than that suggested by previous studies that have focused on a single ses indicator more studies of the independent effects of multiple ses indicators are needed to help improve our understanding of the etiology of obesity in a transitioning society in conclusion individual indicators of ses tended to be positively related to overweight and central adiposity in males and unrelated to overweight and central adiposity in females however once the modifying effects of urban residence were accounted for assets were positively related to overweight and central adiposity among the most rural women but not among more urban women though the prevalences of overweight and central adiposity are low in this sample of young adults we observed a pattern of relationships that is consistent with countries further along in their economic transition this suggests the public health impact of obesity will increase as the philippines develops economically furthermore public health intervention aimed at preventing obesity in the philippines should not assume that higher ses populations are the primary target lastly we recommend that future studies consider the independent effects of multiple ses indicators particularly wealth and education as well as interactions between these individual level characteristics with environmental features such as urbanicity

more research is needed on the socioenvironmental determinants of obesity in lowerand middleincome countries we used generalized estimating equations to evaluate the crosssectional effect of urban residence and multiple individuallevel indicators of socioeconomic status ses on the odds of overweight or central adiposity in a birth cohort of young adult mean age 215 y filipino males n 987 and females n 819 enrolled in the cebu longitudinal health and nutrition survey overweight was defined as bmi 25 kgm 2 and central adiposity was defined as a waist circumference 85 cm for males or 80 cm for females communitylevel urbanicity was measured on a continuous scale multiple indicators of ses included assets income education and marital status in the final multivariable models assets and being married were positively related to overweight and central adiposity in males p 005 but being married was the only predictor of these outcomes in females however once the modifying effects of urban residence were accounted for assets were positively related to overweight and central adiposity among the most rural women but not in more urban women our results are consistent with a growing body of literature that suggests the relationship between ses and obesity is positive in lowerincome contexts and inverse in higherincome contexts particularly in females the pattern of relationships we observed suggests that as the philippines continues to develop economically the public health impact of obesity will increase similarly to what has been observed in countries further along in their economic transition j nutr

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introduction t he human being as a cultural animal has developed various ways of conceiving and relating to nature so that given the almost inevitable human ethnocentric thinking a great diversity of cultures has been generated on the planet which under the current globalizing paradigm must constantly coexist and interact hence concepts such as interculturality have given rise to various debates in academic spaces and have transcended this discussion to political areas in order to understand interculturality it is important to discuss the concept of culture which in the most generalized meaning of the dictionary of the royal academy of language is defined as culture set of ways of life and customs knowledge and degrees of artistic scientific industrial development in an era social group … the united nations educational scientific and cultural organization from the report of the world commission on culture and development in its document our creative diversity points out that culture is not an instrument of material progress it is the end and objective of development understood in the sense of the realization of human existence in all its forms and in all its fullness kowii in the same vein mentions that culture is the expression of the vitality of the existence of individuals who share a natural and social environment at a given time this vitality makes it possible to differentiate and particularize the various human collectivities a definition closer to the latin american reality is offered by the latin american faculty of social sciences which considers culture as the way of living and thinking of a people it is in constant movement and is the sum of internal and external experiences which are nourished by the relationship with the other culture is not a valuable element by itself it becomes valid when we assimilate it through experience which generates possibilities for personal family and community fulfilment the complexity of the concept of culture determines in turn the difficulty involved in defining the concept of interculturality in this regard rodríguez cruz mentions that the polysemy of the interculturality concept is a consequence of the various historical contexts in which it has been used even if in praxis this difference in definitions is not perceived for example in europe the tendency is to define interculturality in terms of the integration of immigrants and ethnic minorities while in latin america the concept is more associated with relations of colonial domination of indigenous communities interculturality requires that the interaction of the various cultures present in a territory generates processes of social transformation in the political social and legal spheres that are reflected in the educational processes of the same state under the practice of recognition respect and effective communication consequently interculturality emerges as an alternative to the concept of multiculturality to provide a new methodological approach and a new way of building knowledge from the recognition of differences moving away from neoliberal models and providing a look at the resistance and the need for the construction of a new society with better social equity the study and the formative proposal presented in this work are part of a participatory process that seeks the construction of an intercultural educommunication model that relates experiences knowledge and expectations of indigenous afroecuadorian and mestizo women the imperative interest of personal and collective improvement through the right to education the need to implement a relevant system that responds to their socioeconomic situation and their family role and provides them with tools to strengthen their entrepreneurial skills and abilities allowing them to overcome barriers in achieving their aspirations and the full exercise of their autonomy in this sense the article provides a historical chronology of the social struggle experienced in ecuador and the progressive changes in the educational system which are still insufficient to meet the demands of the population this is followed by an analysis of the current situation of women in rural areas to compare the effectiveness of the formal education system with field data finally the dimensions foundations and transversal axes that integrate the intercultural educommunication model for the formation of entrepreneurs an essential element of the research are established state of art interculturality in latin america to speak of interculturality is to refer to a heterogeneous dimension of concepts and realities that have been approached in different ways in the continent and ecuador thanks to the extensive presence of native peoples who carry in their heritage the history and wisdom of an extraordinary ancestral heritage and who currently represents between 3 and 10 of the latin american population consequently the construct of interculturality is developed from the theoretical as a concept and from the empirical as a practice which is manifested both in communication and in the establishment of relational processes between different cultures that go beyond just contact and are developed in an equitable epistemological framework therefore it could be said that the term interculturality encompasses several distinctions depending on the author or institution that addresses the category but it has to do directly with the migratory process and human mobility on the continents social configurations that colonization unleashed after the arrival of the spaniards and how the native peoples were displacing their ways of life territories and languages consequently interculturality could be said to be a political proposal born from nationalities and peoples to radically change power structures which opens the way to the improvement of cultural social and economic living conditions interculturality in latin america at the end of the 20th century was a fundamental concept as a political construct for the struggle of indigenous peoples against hegemonic monocultural states which sought to blur cultural differences under the assumption that the political order is subject to universal principles this approach initially became more palpable in the educational sphere and gradually permeated the construction of plurinational states for this ethnic relationship to develop in terms of equality and equity it is necessary to eliminate in discourse and practice the exclusion and discrimination that have historically marked the interaction of cultures in latin america in this sense acosta states that there is no possibility of intercultural development as long as the principles of modernitypostmodernity are maintained within which only monoculturality and multiculturality are accepted as hegemonic systems to preserve the civilizational status thus interculturality goes beyond the process of interrelation and constitutes a process for the construction of knowledge political practices empowerment societies ways of acting and thinking differently and innovatively bringing together the knowledge of diverse cultures interculturality in ecuador in ecuador interculturality has been driven directly and indirectly by the vindictive actions of indigenous movements who have demanded from governments the development of new modes of social relations that allow the recognition of land territory language and education following the preservation of ethnic identity the country has a population of approximately 17000000 inhabitants selfidentified as mestizo 719 montubia 74 afroecuadorian 72 indigenous 70 and white 601 among the indigenous people there are 14 nationalities grouped in a set of local regional and national organizations 603 live in 6 provinces of the sierra centronorte and 785 live in the rural sector this demographic distribution led the ecuadorian state to define itself through the 2008 constitution as intercultural and plurinational which allowed the issuance of laws and regulations necessary to enforce these principles one of the difficulties presented by this recognition process of interculturality and plurinational in ecuador is that it has forged greater representativeness of the indigenous people in the face of the recognition of other ethnic groups which problematizes the actual practice of interculturality the magna carta of 2008 which was cemented in a participatory manner and democratically endorsed by the majority of ecuadorians contemplates principles concepts and dimensions expressed in a vision of society to be built and it was called sumak kawsay subsequently the government has promoted its implementation through objectives policies programs and projects embodied in the national plan for good living however even when the countrys highest legal document delineates the intercultural role of the nation the dominant way in which interculturality is conceived remains linked to traditional positivist thinking and is evidenced as a process of resistance of this paradigm to the changes proposed by the official discourse according to quichimbo it is urgent to rethink the concept of interculturality without leaving aside the perspectives of interculturality from a culturalism and ethnicist vision of indigenous peoples this new recognition of interculturality in ecuador which emerges in a context of recognition of interculturality by the state must find its place in theory and practice detaching itself from hegemonic positions intercultural educommunication educommunication in latin america has been constructed from different perspectives that gain importance from the political to the technical narváezmontoya points out that communication from an ethical and political point of view is closer to what has been known as popular education and has been constituted more as a pedagogical alternative than a theoretical construction this positioning which has been maintained since the 1960s supports the idea that audiovisual media are more effective to educate people due to illiteracy rates and possess geographical and social coverage which prompted latin american marxist and christian movements to use it as an ideological instrument for the education of the masses with the development of educommunication in latin america influenced by popular communication and critical pedagogy communicologists such as mario kaplún and luis beltrán deployed proposals to educate peasant and indigenous communities through radio contributing to the formation of the necessary links between educommunication and interculturality in this way educommunication is developed through a dialogic space that is linked to other areas of knowledge which contributes to building spaces for the exchange of knowledge and its sharing making it an optimal process for the development of interculturality as a consequence of this interdisciplinary relationship the educational transformation brought about by educommunication in the 21st century and currently supported by information and communication technologies has facilitated intercultural dialogue and social cohesion generating intercultural proposals based on a model that contemplates cultures from a perspective of equity and respect for diversity indeed the educommunication we propose is understood as a process of enculturation socialization and subjective in which codes are assumed and under which culture is understood as a code and not as a product so that educommunication is developed in a context of interculturality in ecuador the organic law of communication establishes a structure that encourages the implementation of communicative spaces which can be favored with the promotion of community media which are defined in article 85 as … those whose ownership administration and management correspond to collectives or nonprofit social organizations communes communities peoples and nationalities … in this way an important space is opened for intercultural education and communication as well as for the formation of training networks that allow the democratization of knowledge worldview and development cosmo vision is the human elaboration that recovers the ways of seeing feeling and perceiving the totality of reality that is human beings the whole of nature and the cosmos there are a diversity of worldviews as many as cultures but two that are antagonistic have been differentiated the ancestral indigenous worldview in which the other diversities are grouped and the modern western worldview the practices of human beings in the world will depend on each worldview worldviews mark the differences between cultures being these differences the ones that enrich diversity the ancestral indigenous worldview is essentially based on the experience of living with nature and the community mother earths pacha mama constitutes the big house generator of life and the whole culture thus their practices with her try to be in harmony and respect natural laws while the modern western cosmo vision proposes a state of civilization and development in which the most important thing is the accumulation of capital promoting consumerism as a practice of excessive and unnecessary life these habits imply the destruction of the planet since everything becomes disposable merchandise coming from the industrialization processes that threaten the ecological balance as well as the green revolutions that transgress the seeds and the productivity of the field in this regard it should be noted that from the perspective of indigenous peoples the word development as such does not exist in the kichwa vocabulary but there is a broader concept that in this case is the sumak or allí kawsay this paradigm which has its origin in the dawn of humanity means the way of living seeing perceiving and feeling the universe from the andes being aware that everything that happens in the material and physical environment is a reflection of the invisible essence of our being and feeling this primacy is not a kichwa term that is designed and thought only for indigenous peoples and nationalities but being a constitutional principle established transversally it becomes a condition of life sine qua non for ecuadorians and as such the state through its rulers is obliged to modify the structure of social economic and political development of the country towards this vision of progress is based on the cosmo vision and harmony between human beings and nature the approach of good living or life in harmony is contemplated as a principle of environmental and ecological law of the social and political regime of the country which proposes the search for a better life for all characterized by equity and equality focused on freedom through justice and democracy to achieve sustainability between human beings and mother earth where society is rehumanized in short it has a holistic perspective on the wellbeing of people and the community as it transcends the barrier of the desire to obtain material goods and access public services role of women in the sumak kawsay the andean cosmo vision has relationality as its principle based on the fact that everything is in one way or another related interconnected or coupled nothing endures in isolation esterman refers to the sexual duality between the feminine and the masculine in the sumak kawsay concept proposed by the native people it would seem to be assumed that the relations between men and women inscribed in the cultural frameworks of family and community functioning should not be questioned thus womens political roles are based on domestic tasks since then this is the only thing that confers their status and social prestige as mothers and wives however we assume that as stated by vásquez and saad sumak kawsay is also a conception of life that implies the development of a dignified life in harmony and balance with the universe that is to say the fullness of life in the rural sector the perspective of the sexual division of labor determines that each family member participates in a differentiated and complementary manner for this reason it is necessary to bear in mind when preparing development proposalsthe current and potential contribution of the different members of the family valuing the contribution of each one of them and from the perspective of equal opportunities especially that of women in this regard it should be noted that the fact that male and female activities are complementary in the objective of earning income and maintaining family reproduction does not mean symmetry in the relations between men and women because the family is also a space of inequalities and negotiation while through the yananti a space is presented to justify gender roles and perpetuate inequalities these same principles of division of labor should not necessarily end in inequalities as long as gender positions or occupations do not give rise to power relations the rupture of these relations that produce inequality has led various organizations for the defense of women to rethink the sumak kawsay from the equity in all spaces giving voice to women and establishing shared leadership between men and women in the andean countries from a cultural point of view men and women do not have the same ways of relating to the environment the specificity of rural women in this area is evident in their knowledge use and preservation of the environment which is essential for the treatment of diseases food security habitat management and soil and seed conservation as well as water resource management therefore the recognition of the diversity of its inhabitants is not only important in terms of culture and the countrys development but also in the valuation of womens activities from the perspective of sumak kawsay as the central axis of wellbeing and harmony attention must be paid to gender studies which is fundamental for the achievement of integral development in compliance with the sustainable development goals that constitute a universal call to action to end poverty protect the planet and improve the lives and prospects of people around the world this proposal falls under the policies of objective 5 gender equality and objective 8 decent work and economic growth entrepreneurship in ecuador ecuador is a country with a lot of potential for entrepreneurship development which has been observed as a rising trend since 2016 this led the country to reach first place worldwide among 54 countries analyzed in venture development the data collected in the analysis of entrepreneurship development in ecuador indicate that 50 is carried out by young people but that there is a deficiency in the training of entrepreneurs at the university level or in nonformal education systems which may be related to the fact that a third of the ventures close before two years from their inception in addition to the above gender equity is an important factor to consider when analyzing the development of entrepreneurship in ecuador since this economic activity can favor the local economy in the short term and contribute to improving the situation of women in the social sphere and consequently the economic stability of families however the promotion of entrepreneurship requires adequate policies that establish business conditions for entrepreneurs maldonado et al point out that most of the new ventures fail to achieve stability as new businesses and another percentage are restricted to local commerce and do not expand as a consequence of the lack of training little economic support from private banks and an inadequate political and legal framework therefore overcoming the barriers of the domestic market to access the international market is feasible as long as policies are implemented that open up the possibility of executing technical support programs for the implementation and accompaniment of entrepreneurs as well as the implementation of measures to reduce the limitations created by the formalities finally one way to improve the living conditions of communities must be linked to an increase in the number of enterprises but as mentioned above in addition to appropriate policies more training is required to prevent these enterprises from disappearing in their early years training for entrepreneurs should reach the different levels and modalities of education favoring the development of soft and hard skills from basic school to third and fourthlevel studies similarly in the nonformal educational modality it is necessary to build a public policy that encourages entrepreneurship that promotes entrepreneurial action and innovation for the strengthening of human capital that can be articulated between the popular economy sector and the private business sector methodology imbabura located in the northern andes of ecuador is a multiethnic and multicultural province marked by different demographic factors which give it the characteristic of population diversity 54 mestizo 32 white 9 indigenous 3 black and 2 other the region has diverse climatic levels and ecosystems ranging from the paramo at an altitude of 3600 meters to the chota basin which has a temperate and tropical climate reaching 400 meters above sea level due to the presence of several lake systems it has earned its name as the province of the lakes making it a reference for tourism and product development in the region while at the same time fostering a growing commercial exchange due to its proximity to the border region with colombia objectives of the study considering the characteristics previously mentioned the following question is posed what educationalcommunicative model that considers interculturality and cosmovision can be adequate for the training of women entrepreneurs in the community of imbabura in ecuador in this context the study presented in this article aims at the design of an intercultural educommunication model for the training of women entrepreneurs which recognizes and legitimizes intersectionality interculturality and the gender approach as a sustainable path towards good living or sumak kawsay the methodology used is based on participatory research considering that under this approach it is possible to obtain a higher quality of the information obtained and in turn involve the subjects of the study with the construction of categories and proposals for the development of the research to this end a qualiquantitative method was implemented the subject matter was explored through interviews and surveys which were subsequently processed for the design of the intercultural educommunicative model consequently the impact of the model was reviewed through the analysis of the effects perceived and reported by the participants based on the implementation of this training model and the programs derived from it study participants the construction of the model started with the exploration of the experiences and knowledge of the participants of 3 womens associations in the region of imbabura through the development of workshops which allowed us to obtain the testimonies and ancestral experiences of the leaders and members of the participating associations to this was added the development of direct observation through the recording in field notebooks of the researchers and external participants in addition to the followup through recordings the unstructured interviews began with the women in charge of the various associations and they referred the researchers to other participants whose information was of interest to the research these interviews were previously validated to identify their reliability by specialists in the area of instrument construction entrepreneurship and education the information collected and analyzed was contrasted and crosschecked with bibliographic sources of indigenous afroecuadorian and mestizo thought these associations of women entrepreneurs in the province were chosen based on the criteria of having ethnic diversity among their members maintaining active enterprises and in addition openly expressing their commitment to the research through their informed consent the following associations were selected agricultoras frutos de mi tierra which operates in urcuquí the women of the union of peasant and indigenous organizations of cotacachi la pachamama nos alimenta and finally the womens association las choteñitas was selected made up mainly of afroecuadorian women from the chota valley ibarra procedures for data collection and analysis the construction of the categories of analysis was carried out after discussion and critical analysis by the researchers of the interviews and contrasted with the observations made in the field matrices were constructed that allowed decisions to be made for the subsequent construction of the model and the programs once the programs were developed they were discussed with specialists and with the presidents of the womens associations regarding the quantitative aspect the information was obtained through a questionnaire consisting of 31 questions previously validated through a reliability calculation which was obtained after applying it to a pilot group of women entrepreneurs not related to the associations but belonging to the province to avoid biasing the sample after making adjustments to the questionnaire it was applied to an intentional sample of 84 women taking into account the representativeness of each target canton these data were analyzed through descriptive statistical methods to know the typology of the associates the aspects related to their enterprises as well as their access to and use of icts the use of research techniques made it possible to obtain precise data on the context in which the associations operate and to learn about the existing situation of women entrepreneurs with the inputs collected through bibliographic research critical reading and concept maps an inference and discussion were achieved that supports the premises of the intercultural educommunication model proposed to respond to the training needs expressed by the participants in the study finally it is important to point out that all the approaches made to the respondents and interviewees were carried out after obtaining the informed consent of the participants guaranteeing anonymity the correct use of the data and the commitment of the researchers to present the analysis of the information collected to the womens associations as part of the social responsibility of the research process analysis and discussion the construction of models or programs of formal or nonformal education must respond to the commitment of all social political and intercultural actors of the state which according to garcía and sáez require the following minimum elements for their consolidation a recognize the right of all ethnic groups to contribute their cultural particularities to the educational system guaranteeing this right from the legal framework to avoid any discriminatory process b consider the problems of the cultural identity of migrant groups c take into account the educational needs of minorities within the same cultural group that is diversity within the same diversity and respond to them d promote respect for coexisting cultures and reject any assimilationist proposal e develop intercultural education as content for all members of society and not only as a special educational system for migrants cultural minorities or dominated ethnic groups f promote in society the recognition that problems occurring as a consequence of ethnic diversity cannot be addressed unilaterally g develop an educational praxis based on crosscultural conceptual frameworks that allow the development of knowledge as common property although the elements described above are the premise for the construction of educational models that can positively transform the reality of entrepreneurs the study shows that the level of access to the formal education system in ecuador is exclusive mainly for women and widens the gap in the rural sector within this framework the analysis of the interviews and conversations carried out by applying the focus groups indicate that women unanimously state that there is a supreme will and an imperative need to be educated however the current formal educational system makes it a barrier to the achievement of their aspirations the research included the participation of women living in the rural sector of the cantons that made up the sample 46 of whom selfidentified as afroecuadorian 39 as indigenous and 14 as mestizo regarding the age variable 75 of the afroecuadorian women are between 18 and 55 years of age 81 of the indigenous women are between 26 and 45 years of age and 83 of the mestizo women are 55 years of age or older all of them are part of ecuadors economically active population this is confirmed by the research which determines that only 33 of the women surveyed have completed six years of basic education and 15 although they passed one or more of them did not manage to complete primary education in secondary school the data establish that 14 have completed all the years required by the system and 1785 have completed at least one year of study of those surveyed 7 have not completed any cycle of education and only 115 are currently studying at university concerning education and interculturality urteaga and garcía catalogue it as a limited educational policy at least in the period immediately after the approval of the 2008 constitution in it compliance with the constitutional mandate of interculturality involves the promotion of policies programs and projects that allow access of ecuadorian peoples and nationalities to education at all levels which guarantees their permanence and completion however the data of the study carried out show that only 115 of women are educated at university 14 have completed high school and 33 have finished basic education these data allow us to conclude that public policy in education must be reformed and translated into changes for its effective applicability similarly it can be inferred that formal educational models continue to limit the possibilities and opportunities for improvement especially for women with the situation being more alarming for indigenous and afroecuadorian women in addition the results obtained in the survey demonstrate the existing gap in the right to education showing that it is still inequitable likewise comparing these data with those offered in the countrys statistics it is established that the years of schooling for indigenous peoples and nationalities in ecuador is 64 years being the lowest compared to afroecuadorian peoples who have an average of 84 years and to the mestizo with an average of 98 years of schooling for its part the economic commission for latin america and the caribbean emphasizes that economic autonomy and education are fundamental pillars for achieving equity for this reason our research addressed the issue of economic dependence analyzing variables related to the role of women as heads of household where their economic income comes from and what they prioritize their spending on for the variable of the head of household table 1 shows what percentage of household needs are met by afroecuadorian indigenous and mestizo ethnic groups the results show that the mestizo ethnic group outnumbers the afroecuadorian ethnic group by onethird and the indigenous group by three times this denotes clear behavioral parameters in their habits and culture in the indigenous worldview the figure of divorce or abandonment by a partner is rarely applied although polygamy in their patriarchal behaviors is tolerated social conduct such as adultery committed by women is censored with ancestral justice practices this is ratified by higuera and castillo who refers that interculturality must be reflected in the processes of change in peoples behavior one of the ways to do so is through the educational models of the same state research contributes to the design of educational models based on educommunication under the practice of recognition respect and effective communication changing this reality that is still lived mainly in the ecuadorian indigenous sector due to the economic dependence of women the purpose of this relational approach is to move towards a just society in which differences are respected and the rights of protection and nonviolence to women in the analysis we are carrying out one of the factors that determines the decrease in inequalities is economic independence the research shows that the mestizo ethnic group takes on special relevance concerning the variable economic independence as it highlights the fact that the members of the frutos de mi tierra association are farmers whose average age is over 55 years and older and in addition are heads of household regarding the variable origin of economic income it is determined that 100 of the indigenous and mestizo women surveyed and 875 of the afroecuadorian women obtain their income through activities related to entrepreneurship and if this entrepreneurship is according to need or opportunity the data as we can see in table 2 confirms that women are motivated to achieve economic independence and contribute to their households considering that most of the resources obtained are used for basic services and food for their children which is a general trend in the three ethnic groups the enterprises which generate an important income for the women who took part in this study are mainly developed within the agricultural gastronomic trade handicrafts and activities related to culture and community tourism sectors the latter fundamentally is with the afroecuadorian ethnic group however these productive initiatives are hardly sustainable since the work they do is developed by intuition and without knowledge of basic management tools given this reality it is urgent to design and implement educational models with andragogical axes and nonformal modalities which are an effective and viable training alternative for women especially in the urbanmarginal and rural sectors to acquire skills to improve their entrepreneurial competencies this proposal is corroborated by the united nations childrens fund which conceives the educational system as one of the most important contexts for developing and promoting interculturality since it is the basis of human formation and an instrument not only for the maintenance of a society but also for the development growth transformation and liberation of that society and all its human potentialities in response to these nonformal educational training needs expressed by the women participating in this study the intercultural educommunication model for the formation of women entrepreneurs was designed in response to a regional reality in which women organized in associations are part of a sector of ecuadorian society that in addition to functioning as a fundamental pillar in family and social development are part of a community where it is necessary to develop better gender equity our model is based on the ontological epistemological axiological and praxeological principles which provide an understanding of the characteristics of the meife curriculum design from which the training of women entrepreneurs will be carried out from the ontological foundation the entrepreneur is the axis on which entrepreneurship models have been developed by authors such as ajzen and bandura who identify the conditions that drive the development of entrepreneurship either from the externalities that are related to resources the market and techniques or from internal components such as the entrepreneurs capabilities in these models the entrepreneur is considered as the one who has internal and external motivations that allow himher to seek business development either by necessity or by opportunity whose personal characteristics are the triggers to drive hisher search for personal economic solutions this positioning of the entrepreneur resulting from a referential framework typical of western culture is anchored to the idea of a less collectivist individual who drives family or group businesses from a personal perspective visualizing himself as the manager who incidentally can favor employees or partners it responds in short to the economic theories that have been developed from the approaches of economic liberalism and incorporated into the schools of economics and management globally in a different referential framework such as the one developed through the andean cosmo vision the subject distances himself from individualism and tends to recognize the needs and advantages of collective development the idea of social development is associated with cooperation and mutual support and the subject perceives himherself more as a product of interactions with others than as the result of individual learning actions this understanding of the self under the andean cosmo vision leads to the positioning before reality which translates into praxis as dialogic actions that lead to concrete activities such as for example the minga which are cooperative actions for the care of productive agricultural systems which respond to tacit norms that imply reciprocity equity and respect through the unpaid exchange of labor and knowledge the educational model for the formation of entrepreneurs is based on the premises of the andean cosmo vision ontologically the subject is conceived as an integral part of reality as a participant who constructs destroys and reconstructs relationships with its social and natural tangible and intangible environment which distances it from the position of externalization of the perception of reality finally according to orrego entrepreneurship is an activity that is associated in a complex way with the essence of being and is manifested in the actions that are executed for the transformation and improvement of living conditions traditionally the epistemological foundations associated with careers related to entrepreneurship development are linked to the areas of economics and administration as a cultural heritage of classical schools this implies that the processes are linked to efficiency control and hierarchization of the subjects associated with entrepreneurship all measured by international indicators that assume uniform conditions for all entrepreneurs on a global scale this is an epistemological positioning typical of positivism and assumes the existence of linearity in the causeeffect relationship the rigidity of the positivist approach even when it provides the ability to establish elements of measurement for a partial comparison of the efficiency of entrepreneurship systems and education for entrepreneurship does not fit a process that is fundamentally characterized by emerging from creative and innovative actions therefore more functionalist but equally positivist epistemological approaches were weighed for the analysis of entrepreneurship which considers the role played by subjective elements and organizations within entrepreneurship but remains tied to quantitative indicators therefore in the face of the increasingly widespread recognition of the complexity of the interactions necessary to develop a venture the assumption of systems theory is required to seek new nonlinear logics in line with what prigogine called awareness of discontinuity within which dialogic processes are favored the approach to this systemic complexity that analyzes the human being and society holistically as a super system made up of biological physical chemical social cultural ethical and spiritual systems requires a more integrative epistemological approach hence a hermeneutic paradigm is assumed in the meife to be able to develop the processes of analysis of entrepreneurship and consequently of the training of entrepreneurs due to its greater capacity to deepen the quality of phenomena and contextual relationships both in externalities and internalities in this sense the vision of the entrepreneur from an exogenous and endogenous approach seems to be insufficient to cover in a more adequate way complex and dynamic reality therefore from the exogenous vision the claim is that the entrepreneur is the result of the acquisition of knowledge skills and abilities as it establishes a reduced vision of reality that attempts to be completed when the endogenous vision of entrepreneurship is incorporated however it seeks that individuals possess a universal profile for entrepreneurship and denies the diversity of human beings and their actions a third position focuses on the cognitive theory which although still anchored to the subject as the modulator of the entrepreneurial process does not disregard the action of the environment or of the tasks in which it is involved for this reason based on the andean cosmovision and the ontological foundations already indicated it is assumed that the approach to reality must respond in principle to a subject that is part of the complexity of the phenomenon of entrepreneurship in this way of approaching reality the generalized perception is that individual development is the axis that drives social development and is supplanted by collective development as an action that contributes to social welfare this change of focus not only implies a more immediate approach to social economic development but also more significantly involves the search for social welfare and good living which are inherent to the andean cultural approach the need for education models for entrepreneurship under a systemic and holistic approach is suggested by osorio and pereira to break with the fragmented visions that try to explain the phenomenon of entrepreneurship from the characteristics of the individual the context in which it develops or the business problems of the moment under an andean cosmogonic perspective such as the one presented so far the reality is not only complex in terms of material technical and knowledge aspects but also acquires greater depth in terms of relationships with nature considered from the otherness in processes of recognition of ontological equality therefore the training of the subject to be a participant in the process of entrepreneurship should not be conceived as a set of actions that make up a technical process for professional training as vargas suggests but should be related to the very constitution of the human being this training of entrepreneurs must address a complex reality and consequently it must be generated from equally complex approaches hence it is necessary to consider the scientific knowledge developed from economic theory administration and management from a positivist paradigm but through a multidisciplinary approach that also incorporates aspects of more humanistic training in addition a characteristic of entrepreneurship is its association with high levels of uncertainty as a consequence of being the product of innovative initiatives for this reason meife contemplates that training programs assume a posture that encourages complex thinking and enables the subject to react efficiently and effectively to the variability of systems according to timmons and spinelli the best business opportunities arise in instability and change and entrepreneurs must be prepared for it regarding the axiological foundation education goes beyond the technical training of individuals and is inextricably linked to values which are manifested in the actions goals and interactions of subjects during entrepreneurial actions regulating their behavior if entrepreneurship education is assumed through a linear approach the purpose of the activity is necessarily related to obtaining an economic benefit this is the defining element of the concept of entrepreneurship and consequently the whole model and the colligate educational design will focus its actions on the formation of an economically successful entrepreneur this utilitarian perspective may be beneficial for the individual and state economic indicators but according to álvarez and albuquerque it is necessary to recognize the potential for development that entrepreneurial activity possesses for the formation of a more conscious proactive and ethical citizen this change of approach from a utilitarian one to a holistic one is possible only if entrepreneurship training is developed from another ontological and epistemological positioning different from those that have traditionally governed entrepreneurship the characteristics of entrepreneurs most frequently reviewed by authors show an individual capable of facing risks achievementoriented able to work in teams and adapt to changes and unforeseen events these characteristics are part of what has been called the entrepreneurial spirit and are associated with the formation of a citizen capable not only of developing successful economic actions but also of addressing dynamic social realities efficiently and with adequate foresight to promote social development for this reason meife does not only seek the formation of entrepreneurs focused on business profitability but also attends integrally to the education of a citizen strongly related to the progress of the community balance with the environment and selfconfidence in meife the importance of the integral formation of the subject leads to the development of solidarity and collectivism and finally concerning the praxeological foundation the result of the interaction of the epistemological and axiological frameworks leads to the development of an educational proposal for entrepreneurship which at the praxeological level implies the development of a curriculum design for the training of entrepreneurs supported by experiential and collaborative learning that appropriates the tools of socioconstructivism and enables the development of critical thinking in entrepreneurs bechard and toulouse recognize the praxeological level of entrepreneurship as that which combines the practice limited by the axiological foundations and its effect on the development of entrepreneurship in other words it is the ethical and moral foundation proposed in the meife that will make it possible to achieve the proposed goals therefore the action of the theoretical foundations mediated by the ethical elements is based on the considerations that are assumed to form the structure of the educational design for the formation of entrepreneurs in this regard osorio and pereira had already emphasized that the entrepreneurial training processes guided by universities should start from the recognition of the intentions and expectations of individuals but also of personal beliefs and aspects of the environment in line with the above universities have a clear responsibility to consolidate the necessary synthesis of theoretical ethical and practical concepts for the training of entrepreneurs therefore the academic and research training functions that higher education institutions have been fulfilling have been evolving based on the coordination of actions with industries and the government which implies as etzkowitz and leydesdorff point out that their contribution to the nations economy should be considered as an additional function of universities meife proposes therefore a praxis that manifests itself as a process of lifelong learning that values the opportunities present in the environment but also those opportunities that can be created by the subject based on an analysis of the complexity of the system the system in turn is a dynamic reality that must be analyzed and constructed from reflective knowledge complemented by a dialogic process consequently opportunities are not conceived as an element only external to the entrepreneur but as the result of the training that allows reaching the necessary competencies for the construction of their opportunities from the interiority of the entrepreneurs being as a complex cognitive process this dimensioning of the training model presented differs from the rest because it acts within a communicational ecosystem that involves the participation of multiple actors at different levels of relationship through a dialogue of knowledge conclusions the presence of women among people living in poverty the lack of sufficient income the overload of unpaid work and unemployment rates systematically higher than those of men show that there are still fundamental challenges to be faced for men and women to live in conditions of equality and to enjoy their rights to achieve sumak kawsay the construction of an educationalcommunicative model for the development of enterprises that allow women in ecuador to improve their economic situation and achieve demands in other social aspects includes dimensions that consider the cosmovision as an identity element to this end cultural particularities are recognized and assumed within the training process following the legal framework to avoid discrimination this model is the frame of reference for the development of training programs for women entrepreneurs that help to overcome the restrictions found in the group of interest in which it is observed that the relationship between the level of education and the level of economic income is maintained in addition an average of 78 of afroecuadorian and indigenous women are of economically productive age which is an indicator of interest because it is related to intrafamily poverty with which meife and subsequent educational programs can contribute to improve the economic level of this population and consequently improve family income due to the correspondence that exists between this population group and their position as breadwinners women from the three ethnic groups participating in the study spontaneously stated that there is a strong will and a dominant need to be educated in a system that allows them to integrate their entrepreneurial skills that responds to their socioeconomic situation and their family role and provides them with tools to strengthen their abilities and skills that encourage them to overcome barriers in achieving their aspirations and the exercise of their autonomy that guarantees empowerment at all stages of the process for its sustainability over time the analysis of the information obtained in the working groups with the women leaders of the associations establishes the limitations of the current educational system they ratify their desire to participate in the construction of nonformal education processes that contemplate specific thematic areas concrete and following the dynamics of their enterprises which promote the permanence of the economicproductive initiatives they carry out through a systematic training supported by icts based on this collective pronouncement the intercultural educommunication for entrepreneurial training model is proposed which consolidates knowledge and skills in the implementation of innovative product ideas with value addition commercial and business management that allows them to work in dignified and equitable conditions by applying what they have learned in knowledge practice and attitude the model explained in previous texts promotes its dimensions foundations and transversal axes the preservation and reproduction of traditional knowledge maintained for decades in the communities embodied in the andean cosmo vision as a harmonious relationship with mother earth data availability the datasets generated during andor analysed during the current study are available from the corresponding author on reasonable request the data are not publicly available due to them containing information that could compromise research participant privacyconsent competing interests the authors declare no competing interests ethical approval this study following the guidelines of the ethics committee of the university of salamanca and has been carried out in accordance with the code of ethics for research in education and its subsequent amendments or comparable ethical standards informed consent the authors declare that informed consent was obtained from all study participants each of the presidents of the associations participating in the study signed the informed consent prior to their participation in the research additional information correspondence and requests for materials should be addressed to ana iglesias rodríguez reprints and permission information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the education system in ecuador has historically been structured in a way that excludes women especially those living in the urbanmarginal and rural sectors where access and permanence are hindered by socioeconomic and cultural factors the objective of the study is the design of an intercultural educommunication model for the training of women entrepreneurs meife which recognizes and legitimizes intersectionality interculturality and the gender approach as a sustainable path towards good living or sumak kawsay the methodology used is based on participatory research that includes a qualitativequantitative method in which direct observation interviews and surveys were used as techniques the design was elaborated considering sources of indigenous afroecuadorian and mestizo thought the study shows that the education system for women in imbabura widens the gap in the rural sector only 33 of the women surveyed have completed six years of basic education and 15 although they passed one or more courses did not finish regarding secondary education 14 of women have completed all years of secondary education and 1785 have attended one year of study seven per cent of the women surveyed had not attended formal education in response meife is a nonformal education tool aimed at women entrepreneurs developed taking into account the indigenous worldview who form part of a community where it is necessary to create opportunities and encourage initiatives that allow them to generate income and guarantee their autonomy in coherence with their ancestral culture

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introduction financial institutions government agencies think tanks etc are using techniques like agentbased modelling bonabeau to simulate increasingly complex scenarios for decisionmaking however the collection of such extensive datasets needed for model training and agentbased modelling are constrained by realworld challenges such as high costs of acquisition privacy laws etc figure 1 our framework preprocessed data is used as input for generating data moreover population censuses and various other surveys eg for health economics education etc help inform public policy decisionmaking periodic censuses and surveys provide aggregate statistics on variables describing the demography socioeconomic distribution and health status of the constituents at various levels of zoom they also help decisionmakers examine the effects of previous public policy decisions on the evolution of these statistics surveys that provide data at an individual level instead of marginals are of particular interest as once released they allow for superior analysis of correlations between different attributes however data collection for censuses and surveys is a timeconsuming and expensive task especially for low and middleincome countries for example the last census in india during 2011 involved a total of 27 million enumerators and supervisors costing approximately inr 22000 million further national censuses do not often release fullscale individual data for public access due to privacy reasons which limit the potential for analysis in light of these challenges privacypreserving synthetic populations can be used as an alternative to real individuallevel datasets to increase the accuracy of downstream tasks it is essential that the marginal and joint distributions of the various attributes are similar across the original and the synthetic population further to address privacy concerns it is necessary to ensure that the synthetic dataset does not leak any personally identifiable information about the individuals who were originally surveyed additionally with the growing complexity of agentbased models it is necessary to generate synthetic datasets where individuals are parts of networks and the linkage is based on shared attributes like a household a workplace a school common direction of travel etc preexisting frameworks for synthetic population generation are limited in this regard to focus our discussion we will explore the task of generating a synthetic population with the use case of modelling disease spread throughout this paper in this context we make the following contributions the rest of the paper is organised as follows section 2 is about related work to generate a synthetic population in section 3 we describe our model in detail the experiments and evaluation are presented in section 4 we discuss future work and conclude in section 5 related work in the task of modelling and generating synthetic populations there are various challenges in modelling the tabular data for example a table might have mixed data types with discrete and continuous columns the columns in the table might not follow say the gaussian distribution further a column might have multimodal distributions the data may also be highly imbalanced resulting in insufficient training opportunities for minor classes some abms require the synthetic population to be realistically geolocated which to the best of our knowledge has not been attempted especially not for india though various methods have been suggested to tackle these issues they do not provide a solution to the issues specified for example bayesian networks koller friedman combine low dimensional distributions to approximate the fulldimensional distribution of a data set and are a simple but powerful example of a graphical model but bayesian methods can not model tabular data effectively when both continuous and discrete columns are present deep generative models are generally more sophisticated but in practice can not outperform bayesian methods as the tabular data may contain nongaussian continuous columns andor imbalanced discrete columns some methods have tried to mitigate these issues privbayes zhang et al can model the table with discrete variables but all continuous variables need to be discretised additionally noise injection to preserve privacy may result in lowquality synthetic data medgan choi et al has been used to generate health records but it does not support mixed data types it also can not handle nongaussian multimodal imbalanced categorical columns lack of training data and missing data although ctgan xu et al can work with tables with mixed data types high dimensionality imbalanced categorical data etc it can not handle a lack of training data and missing values also it can not model realistic family structures iterative proportional updating ye et al can work with limited data and model realistic family structures but it does not scale well with high dimensional data to tackle these issues we propose our framework which uses a hybrid as shown in diagram 1 of ipu and ctgan to take advantage of the best from these two models our framework allows for combining data from various sources and generates a synthetic population with required columns our framework our objective is to generate a realscale synthetic population for an entire country with distributions and joint distributions of various variables that match those of the actual population this is necessary to ensure that the results of the downstream tasks are reliable a synthetic population is a limited individuallevel representation of the actual population however not all the attributes of an individual are included as such a synthetic population does not aim to perfectly mimic reality this would be impossible instead it attempts to sufficiently match various statistical measures observed in the real population the components of any pipeline used for generating a synthetic population would largely depend on the variables that are required for the downstream task as stated earlier our pipeline as shown in diagram 1 is built with a focus on synthetic population data for districtlevel infectious disease modelling for the chosen downstream task the synthetic population should capture various heuristics like the size of a family the joint distribution of age and sex of individuals within a family administrative units like cities districts and states geographical distribution of households workplaces and schools within an administrative unit the number of people who are associated with a workplace or school and various other individuallevel statistical correlations that can be observed in any population iterative proportional updating and conditional tabular gan were used to generate families and individuals and their related metadata further reject sampling was used to sample geolocation points within a citys boundaries which followed the per unit area population density distribution a method for random assignment of external locations like workplaces schools and public places was used where the probability of selecting any external location was inversely proportional to the distance between a given individuals household and the external location ministry of education data generation with family structure ipu ye et al is a sampling method which ensures that the marginal distributions for both households and individuals in the synthetic population match with the marginals distributions of the real population hence sampling with ipu helps generate a population in which households have a realistic distribution of the number of family members and their age and gender however matching only marginal distribution is not enough we must closely resemble the joint distribution of various attributes in the population to achieve this we use ctgan xu et al for adding individuallevel attributes for which marginals are not available the ctgan model can be conditioned on attributes present in the base population generated by ipu to generate additional attributes thus using ctgan we can get a reasonable joint distribution of various individuallevel attributes in the synthetic population additionally multiple ctgan models can also be used to join survey datasets which have an overlapping set of attributes this allows for the expansion of attributes as per the needs of the downstream task population density distribution sampling given that the downstream task is to analyse the spread of infectious diseases in a given region it is necessary to have an accurate geographical distribution of population density and workplace density to this end grid population density data gaughan et al is used a row in the grid population density data consists of latitude longitude and the number of individuals who live within a square with edge length s and with its centre at the given latitude and longitude for the data set used in the current pipeline the length of the side of square s 03 arctan translates to a length of about 1 km on the equator the sampling method also needs a polygon for the boundaries of the region for which data is being generated we use the geojson file for each district to get these geographical boundaries let n be the number of latitudelongitude pairs that need to be sampled within this region a filtered subset of the population density dataset is obtained by only retaining those rows for which the latitude x and longitude y are within the boundary polygon of the region we sample with replacement k latitude longitude pairs from this filtered subset and use the number of individuals as the weight for this sampling for a given row in the sample we then sample points within the squares corresponding to the latitudelongitude pair by adding independent random uniform noise a b ∼ u to the latitude x and longitude y respectively we reject those latitudelongitude pairs that are not within the polygon given this method uses reject sampling we initially need to sample more points than required and hence we need to use a suitable value for k n and then choose at random from the pairs which were not rejected we use this method to assign geolocation to houses workplaces schools and public places given we do not have access to workplace distribution data we assume that it follows the population density distribution as well however this assumption is not valid in cities where people live in outer sub urban areas and work closer to the city center and other possible scenarios with the appropriate dataset we can substitute the population density data with workplace density data and get a distribution similar to the ground reality with the sampling method described earlier external location assignment since infectious disease modelling often includes analysis based on contact network graphs individuals in this synthetic population would need to be associated with external locations like workplaces schools and public places which they might visit periodically this assignment is based on the assumption that adults work at workplaces children go to schools and people are more likely to visit public places which are closer to their homes we use the l2 distance metric for this computation since the earths curvature within a city is negligible but a geodesic distance metric can also be used given an individual with home latitude x h and longitude y h and a list of possible external locations with latitude longitude pairs we calculate the l 2 distance between the home of the individual and the external location then we choose a function f which is strictly decreasing in the positive real domain then we weigh the probability of the individual being assigned the external location by the value f where d is the l 2 distance in 2 dimensions experiments and evaluation datasets as mentioned in our framework section we use various datasets as input to our framework we use sample survey data from india human development surveyii desai et al marginals from census 2011 office of the census commissioner of india data for employment from nss national sample survey office nsso and population density from gadm grid population density dataset j hijmans the ihdsii 201112 is a nationally representative multitopic survey of 42152 households in 1503 villages and 971 urban neighbourhoods across india we have used microdata from two datasets from this survey namely individual and household as input to the ctgan model the census of india 2011 was done across 28 states and 8 union territories covering 640 districts 5924 subdistricts 7935 towns and more than 600000 villages we use marginal data from census 2011 as input to ipu the nss collects data through nationwide sample household surveys on various socioeconomic subjects we have used employment data from this survey gadm provides maps and spatial data for all countries and their subdivisions we used population density data for india to place the generated synthetic population across geography in the next section we describe how to use these different datasets as input to our hybrid model to generate a synthetic population for a district of india generating synthetic population a synthetic population for agentbased disease modelling should have demographic socioeconomic healthrelated and geographic variables for each individual in the population we will now describe the steps for generating a synthetic population for the district of mumbai located in the state of maharashtra in india as discussed in the previous section we use marginals for individual and household attributes from census 2011 for individuals the relevant attributes are age sex2 religion and caste for households the attribute is household size ie the number of members in the household we also use a subset of ihdsii dataset obtained by filtering for individuals and households which are situated in the state of maharashtra we use the filtered datasets for maharashtra because the mumbai dataset in ihdsii contains a few hundred samples which are not enough for our model to generate quality synthetic population we then use ipu which use the marginals and the microdata to generate households of varying sizes each household has a certain number of individual family members each with their own age sex religion and caste there may be some shared attributes between family members like common religion and caste further the distribution of age and sex of members within a family of a given size resembles that of a typical family of the given size that one would expect to see in the real world we then sample latitude longitude pairs using the method described in section 32 for each household the same household latitude and longitude is attached to each member of the household we add individual level attributes like weight height comorbidities and job description for weight height and comorbidities we use a ctgan model conditioned on age and sex the ctgan model is trained on the subset of ihdsii dataset containing individuals situated within the state of maharashtra for individuals below the age of 3 homebound is assigned as the job description for individuals above the age of 3 and below the age of 18 student is assigned as the job description for individuals the job description is sampled with replacement from the list of job descriptions of the individuals in the ihdsii subset the weight assigned to each possible job description is linearly proportional to the distribution observed in the ihdsii subset for maharashtra next we generate synthetic workplaces schools and public places for our synthetic individuals the number of workplaces schools and public places is a parameter that varies for each district each workplace has three attributes workplace type latitude and longitude the attribute workplace type is generated by sampling from the list of jobs in the ihdsii subset latitude and longitude pairs are sampled with the method described in section 32 schools are obtained by filtering for a subset of workplaces with workplace types set to teacher next we assign schools to students and workplaces to individuals who are not homebound or students assigning schools in straightforward as we use the method from section 33 the final synthetic population has demographic data disease data family data geographic location for workplaces schools etc and socioeconomic data in total we generate a synthetic population with 44 columns a sample of our synthetic population is shown in the appendix evaluating synthetic population according to census of india 2011 office of the census commissioner of india the district of mumbai had a total population of 3085411 and the district of mumbai suburb had a total population of 9356962 we generated the synthetic population for these two districts combined we evaluate this synthetic population and present our results here 2018 uses classification and regression tasks to validate the synthetic population we evaluate the synthetic population based on the following three criteria • distribution of individual features in synthetic population match those in sample surveys ie histogram should look similar • joint distribution of selected features in synthetic population match those in sample surveys ie scatter plot should look similar • relationship between features and selected target variable in synthetic population match the same in sample survey the marginal distribution has similar shapes even though the synthetic population is real scale figure 4 juxtaposes the scatter plots of attributes of age height and weight for real and synthetic populations the scatter plots depict the joint distributions which are roughly similar across the real and the synthetic population figure 5 helps visualize the geographic distribution of synthetic households workplaces and schools in the combined districts of mumbai and mumbai suburban due to space constraints the population pyramid and the box plots are placed in the appendix confidence that the synthetic data and the real data come from the same distribution we also use the kolmogorovsmirnov statistic to compare the marginal distributions of continuous numerical data we report a score of 1 a higher score again indicates the confidence that the synthetic data and the real data come from the same continuous distribution another set of tests we conducted to evaluate if our synthetic population can replace the real population to solve a machine learning problem we first attempt to predict the weight based on age sex and height similarly we attempt to predict the height based on age sex and weight for this experiment we use two ml models linear regression and multilayer perceptron regressor first we train and test the models on real data next we train the models on the synthetic data and test the model performance on the real data the comparative results are shown in table 2 our results on bharatsim bharatsim an agentbased model is capable of allowing for complex social dynamics realworld systems involve interactions between individuals with different attributes and geographies these interactions lead to emergent phenomena while events like a pandemic affect individuals according to their attributes agentbased modelling accounts for individual differences and allows us to simulate scenarios of varying complexity these simulations can guide policylevel interventions the synthetic population gives us information on the homes and workplaces of all agents in the population and the individuals movements in a day are charted by defining a schedule specific to that individual which decides how individuals move back and forth between their homes and workplaces or schools during a day the infection spreads stochastically between individuals who share a location at any given time at rates determined by the infection parameters in this model we have constructed a simple sir compartmental structure tolles luong describing a hypothetical disease susceptible individuals can be infected at a rate proportional to the fraction of infected individuals they are in contact with the constant of proportionality which determines how infectious the disease is is agestratified once an agent is infected it can infect other individuals until they recover the time to recovery is assumed to be drawn from an exponential distribution with a mean of 7 days for a simulated lockdown individual agents schedules are modified so that they remain at home all agents are required to follow this rule except those that are designated by the synthetic population as essential workers and those who have a low probability of adherence to policylevel interventions whether or not an individual falls into the latter category is decided by comparing a random coin toss to their adherence to interventions value the reduction in the number of people in different network locations thus reduces contact between individuals and restricts the spread of the disease in our simulations we have considered two counterfactual scenarios one in which a lockdown is imposed when the number of active cases is 1 and 2 of the total population respectively as can be seen in figure 6 the lockdown flattens the curve keeping the peak in active cases low additionally starting the lockdown earlier is much more effective in curtailing the spread of the disease in our simulation the results are averaged over 20 runs with the individual runs in the background conclusion and future work in this paper we propose synthpop a novel hybrid framework for generating synthetic populations at various scales ranging from a few thousand to a billion individuals we also suggest a combination of metrics to verify the generated synthetic population future work would include the exploration of methods to generate a synthetic population without the need for sample survey data as well as the modelling of complex features such as economic variables another target would be a realistic intracity geographical distribution of individuals depending on their demographic and socioeconomic attributes additionally some analysis tasks might require a dataset with a specific combination of attributes for which a survey has not been conducted a method which can combine two or more datasets with different partially overlapping sets of attributes can be used to generate a synthetic population with the specific set of attributes a appendix a1 synthetic population summary statistics and charts

population censuses are vital to public policy decisionmaking they provide insight into human resource demography culture and economic structure at local regional and national levels however such surveys are very expensive especially for low and middleincome countries with high populations such as india timeconsuming and may also raise privacy concerns depending upon the type of data collected in light of these issues we introduce synthpop a novel hybrid framework which can combine data from multiple realworld surveys with different partially overlapping sets of attributes to produce a realscale synthetic population of humans critically our population maintains family structures comprising individuals with demographic socioeconomic health and geolocation attributes this means that our fake people live in realistic locations have realistic families etc such data can be used for a variety of purposes we explore one such use case agentbased modelling of infectious disease in india to gauge the quality of our synthetic population we use machine learning and statistical metrics our experimental results show that synthetic population can realistically simulate the population for various administrative units of india producing realscale detailed data at the desired level of zoom from cities to districts to states eventually combining to form a countryscale synthetic population

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introduction according to the global status report on physical activity 2022 around 81 of children aged 1117 do not meet world health organization physical activity recommendations the who global action plan on physical activity 20182030 aims to reduce this prevalence and one strategy focuses on strengthening physical activity surveillance across the lifespan the active healthy kids global alliance has made a significant contribution to this endeavor worldwide the alliance developed a standardized global surveillance system focused on evaluating the prevalence of movement behaviors among children and adolescents and the opportunities available to perform these this global survelliance system employs a movement behavior paradigm where behaviors that contribute to children and adolescent movement are examined separately physical activity sleep active play active transportation and sedentary behavior as opposed to only focusing on physical activity the movement behavior paradigm offers a more granular evaluation of movement among children and adolescents while identifying several intervention points the ahkga evaluation results are presented in the global matrix of report cards on physical activity for children and adolescents for the global matrix a standardized evaluation methodology is followed where several countries develop report cards in which grades are assigned to movement behaviorrelated indicators four global matrices have been completed to date the latest one in 2022 where 57 countries from six continents completed report cards as part of the global matrix mexico has developed four report cards that have improved the surveillance of movement behaviors in mexican children and adolescents this manuscript reports results from the 2022 edition of the mexican report card which aims to provide an uptodate evaluation of movement behaviors among mexican children and adolescents and to inform programs and policies to improve these behaviors this is particularly important after the negative impact the covid19 pandemic lockdown had on physical activity and sedentary behaviors in mexican children and adolescents methods the mexican report card is a national surveillance system that qualitatively assesses secondary data to monitor movement behaviors among children and adolescents as well as the opportunities families communities and government offer to perform these behaviors the development of the mexican report card follows three main steps identification of data sources for each indicator comparison of the data gathered against established benchmarks and grade assignment the 2022 edition of the mexican report card evaluated 11 indicators grouped into four categories presented in table 1 the primary data sources for this evaluation included nationally representative surveys census and government documents to assess daily behaviors we reviewed data from the national health and nutrition survey 2016 2018 the intercensal survey 2020 inegi and the profile of upper secondary education students 2019 for physical fitness data we used the 2020 covid19 ensanut given the different methods employed in these sources sample sizes for these indicators significantly vary to assess sources of influence we consulted the 2014 national survey on the use of free time the national education system 20192020 report if nationally representative data were lacking research articles published between 2013 and 2021 reporting relevant data on children and adolescents 518 years of age were reviewed when new data were not available to assign a new grade for the 2022 report card the data source and grade from the previous edition of the report card were used when available data about the effects of the covid19 lockdown on movement behaviors were also examined the data was gathered between 2020 and 2022 after data were gathered the report card team met to assign a grade to each indicator data obtained were compared against preestablished benchmarks and a grade was assigned based on the proportion of children and adolescents reaching the benchmark the benchmarks and grading system were established and standardized by the ahkga the assigned grades are based on the mexican grading system which ranges from 0 to 10 where numbers below 6 represent failing grades and 10 a perfect grade these grades correspond to the letter grading system other countries use during grade assignment national data took precedence over regional data age and gender disparities were also considered for example if age or gender differences were observed for a given indicator the grade was lowered by one point grades were assigned as follows results of the 11 indicators evaluated in the 2022 mexican report card 5 obtained approbatory albeit low grades and 6 obtained failing grades these grades suggest that except for sleep movement behaviors are below recommended levels among mexican children and adolescents particularly among girls while opportunities to engage in such behaviors are limited hence the theme and cover of the 2022 mexican report card aims to shed light on this disparity girls get to play too this theme highlights the fact that mexican girls are being left behind and aims to spark actions directed at providing mexican girls with the same physical activity opportunities boys enjoy physical activity 3 data from ensanut 2018 show that only 154 of children 1014 years old and 537 of adolescents 1519 years old accumulate at least 60 min of moderate to vigorous intensity physical activity per day the proportion of boys that meet this recommendation is higher than that of girls in both age groups the proportion is also higher in rural than urban areas in children and adolescents in the ensanut covid 2020 national survey 688 of children aged 1014 and 600 of adolescents aged 1519 years old reported a decline in the time spent on physical activity or sport based on the low prevalence of physical activity and the declining trend a grade of 3 was assigned to this indicator participation in organized physical activity and sport 5 ensanut 2018 reports that 486 of children 1014 years old participated in some form of organized physical activity or sport in the last 12 months girls report lower participation than boys a lower proportion of children in urban areas participate in organized physical activity or sports than children in rural areas the current participation of mexican children and adolescents in organized physical activity and sports earned this indicator a grade of 5 indicator benchmark daily behaviors physical activity of children and adolescents that accumulate at least 60 min of moderate to vigorous intensity physical activity per day organized sport and physical activity of children and adolescents who participate in organized sports andor physical activity programs active play of children and adolescents who engage in unstructuredunorganized active play at any intensity for more than 2 h a day active transportation of children and adolescents who use active transportation to get to and from places sedentary behaviors of children and adolescents who spend no more than 2 h of recreational screen time per day sleep of children and adolescents who meet canadian sleep recommendations 911 h a day for girls and boys 513 years and 810 h a day for adolescents 1417 years old physical fitness of children and adolescents have a body mass index that is adequate for their sex and age sources of influence family of parents who meet the global recommendations on physical activity for health which recommend that adults accumulate at least 150 min of moderateintensity aerobic physical activity throughout the week or do at least 75 min of vigorousintensity aerobic physical activity throughout the week or an equivalent combination of moderateand vigorousintensity activity throughout the week school of schools where most students are taught by a physical education specialist of schools with students who have regular access to facilities and equipment that support physical activity community of communitiesmunicipalities that report they have the infrastructure specifically geared toward promoting physical activity of parents who report living in a safe neighborhood where they can be physically active government evidence of leadership and commitment in providing physical activity opportunities for all children and adolescents allocated funds and resources for the implementation of physical activity promotion strategies and initiatives for all children and adolescents demonstrated progress through the key stages of public policy making physical fitness also includes the evaluation of cardiorespiratory fitness muscle strength muscle endurance and flexibility however since no national data was found to assess these only body mass index was considered for the grade assessment 103389fpubh20231304719 frontiers in public health 04 frontiersinorg active play 4 there were no national data to evaluate this indicator five studies reporting data on active play among mexican children and adolescents were identified and the grade for this indicator was based on their data a study conducted in morelos reports children aged 912 years spend between 1823 h a day in active play another study reports that children aged 25 years in mexico city spend approximately 38 h a day in active play furthermore a study that included mestizo and tarahumara children aged 614 years found that 45 of tarahumara children spend more than 4 h per week in active play compared to 27 of mestizo children a study among 1509 children ages 611 from guadalajara mexico city and puerto vallarta reports that 76 play outdoors at least 1 day per week finally a study of 403 mexican students 1520 years old examined the time they spend per day in active play where 56 were classified as active in their leisure time together these studies show that mexican children and adolescents from different regions in the country spend around 24 h a day in active play thus a grade of 4 was assigned to this indicator active transportation 5 data from the intercensal survey 2020 shows that 541 of children over 3 years of age walk to school while 18 use a bicycle the 2019 student profile survey from the mexican ministry of education reports that 205 of students over 15 years of age commute to school by walking 21 by riding a bike and 013 by skateboarding these data suggest that active transportation is low among mexican children and adolescents hence a grade of 5 was assigned sedentary behavior 4 data from ensanut 2018 show that 436 of children between 10 and 14 years old spend less than 2 h per day in front of a screen these levels are similar in boys and girls more children in rural than urban areas meet this recommendation ensanut 2018 also reports the time spent sitting per day is higher among 1519yearold girls than boys during the covid19 lockdown 412 of children aged 1014 years and 355 of adolescents aged 1519 years reported an increase in the time spent sitting or reclining these levels of sedentary behavior earned this indicator a grade of 4 sleep 7 ensanut 2016 data shows that 91 of children aged 1014 years sleep at least 9 h a day where more girls than boys meet this recommendation this data also shows that 65 of 15 to 17yearold adolescents sleep at least 8 h per day this data suggests that twothirds of mexican children and adolescents are getting the recommended sleep for health which granted a grade of 7 to this indicator physical fitness 6 the physical fitness indicator includes the assessment of body mass index cardiorespiratory fitness muscle strength muscle endurance and flexibility because national data was only available for body mass index the grade for this indicator was based on this component data from ensanut covid 2020 shows that 618 of children 511 years have an adequate body mass index for their age ensanut covid 2020 data shows that 562 of adolescents aged 1219 years have adequate bmi values for their age more children in rural areas have adequate bmi values than children in urban areas based on the proportion of mexican children and adolescents who have an adequate bmi for their age a grade of 6 was assigned data from the national free time use survey 2014 shows that between 65 to 67 of parents engage in physical activity the survey also reports parents accumulate an average of 230 min of physical activity per week based on this a grade of 7 was assigned school 6 the national education system 20192020 report shows that 334 of preschools 533 of primary education schools and 322 of secondary education schools have a physical education teacher the 2013 census of schools teachers and students of basic and special education reports that 639 of public schools have sports and recreational areas while 768 have patios in private schools these percentages are higher 85 have sports and recreational areas while 91 have patios with the data available we could not assess the frequency and duration of the physical education classes that children and adolescents receive at school we also identified schoolbased initiatives aimed at promoting physical activity but we found no data to assess if these were implemented and what effects they achieved when averaged the available data show 40 of basic education schools have a physical education teacher while 79 of schools have spaces for children to engage in physical activities thus a grade of 6 was assigned community and built environment 4 according to the 2020 population and housing census 37 of the neighborhoods have sidewalks and trees 134 have public lighting and 65 have ramps for wheelchairs further 05 of the total number of roads in towns with ≥5000 inhabitants have bicycle paths or cycle lanes regarding safety the 2020 national survey of victimization and perception of public security data show that 62 of adults have stopped allowing their children to go outside due to low safety perception additionally data from the sports practice and physical exercise module 2020 shows that 60 of the physically active population reports going to public facilities to perform physical activities finally according to the health sector program 20132018 83 spaces for physical activity have been reactivated and recovered benefiting 219427 inhabitants based on this a grade of 4 was assigned to this indicator finally the national plan for physical culture and sports 20212024 has three objectives that seek to promote recreational and competitive sports participation in an inclusive manner the education sector program 20132018 included an objective aimed at placing physical activity and sports participation as an integral component of children education it established actions to strengthen the sports infrastructure in the educational system promoting physical activity and sports participation in educational institutions and the promotion of physical activity in extracurricular hours for children and adolescents information about the results of these actions is lacking for the 20202024 period the education sector program established objectives to guarantee the right to physical culture and sports with an emphasis on integrating schools social inclusion and promoting healthy lifestyles in schoolage children the program prioritized the promotion of physical activity play and sports participation in schools and the participation of children from all socioeconomic groups regarding investments we found no information on the specific budget allocated to physical activity promotion policies and programs in the 20132018 government period according to the evaluation of consistency and results of the physical culture and sports program in 2017 progress was observed with respect to the percentage of support offered to members of the national sports system in terms of sports infrastructure with a value of 111 with respect to a goal of 100 in contrast the percentage that municipalities in mexico allocated to sports participation was 018 regarding other resources the annual program of physical culture and sports 2021 assigned 26764987750 mexican pesos for strategies to promote sports participation concerning leadership the government documents and reports reviewed here do not clearly delineate the responsibilities of the different sectors involved in the design and implementation of the programs and policies introduced in sum no considerable progress was identified between 2013 and 2020 around investments policies and programs aimed at promoting physical activity in mexican children and adolescents hence a grade of 6 was assigned to this indicator discussion the 2022 mexican report card is the most comprehensive evaluation of movement behaviors and related opportunities among mexican children and adolescents we evaluated 11 indicators where five obtained approbatory grades and six obtained failing grades except for sleep all movement behaviors evaluated received failing grades which indicates mexican children and adolescents are not meeting the recommended levels for these behaviors particularly girls in terms of opportunities the 2022 mexican report card grades show families schools communities and the government are not providing sufficient opportunities for mexican children and adolescents to perform healthenhancing movement behaviors though these grades suggest mexico is not on track to meeting the global action plan on physical activity 20182030 goals they highlight several opportunities for improvement daily behaviors except for sleep all daily behaviors evaluated received failing grades indicating less than half of mexican children and adolescents are meeting the recommended levels for these behaviors girls have lower levels of physical activity and sports participation than boys of the same age this has been a recurring finding in each edition of the mexican report card and could speak to gender stereotyping which has been identified as a barrier to physical activity the mexican culture traditions and gender norms dictate girls should movelook certain ways which limits opportunities for girls to move more hence the theme of the 2022 mexican report card girls get to play too aims to shed light on this disparity and to spark actions directed at promoting movement behaviors among mexican girls based on the global matrix 40 estimates mexicos average grade across daily behaviors indicates between 40 to 46 of children and adolescents are meeting recommended levels for movement behaviors these estimates align with those reported in the colombian report card and are higher than those reported in the argentina brazil chile and uruguay report cards finally the covid19 pandemic in mexico negatively impacted three of the daily behaviors evaluated physical activity and sports participation decreased while sedentary behavior increased though this was not penalized in the grades reported here it echoes what report card leaders from the countries participating in the global matrix 40 reported and calls for efforts to counter the adverse effects the pandemic had on children and adolescent movement compared to grades in the 2018 mexican report card the sedentary behavior grade increased from 3 to 4 given that the proportion of girls and boys aged 1014 years who spend less than 2 h a day in front of a screen rose from 33 reported in ensanut 2012 to 44 reported in ensanut 2018 for active play the grade increased from 3 to 4 given that more regional data were identified providing a better understanding of this behavior but no tangible improvements were observed in contrast the physical activity grade dropped from 4 to 3 given that physical activity levels decreased among children from 172 to 154 and in adolescents from 61 to 537 according to ensanut 2016 and 2018 respectively active transportation sports participation and sleep grades remained the same as in 2018 because they were based on the same data at the time this evaluation was completed no new data was available to update these grades although the small grade improvements observed are promising those that did not change or worsen indicate mexico is not on track to meeting the global action plan on physical activity 20182030 goals physical fitness the 2022 physical fitness grade shows that around 60 of mexican children and adolescents have an adequate bmi for their age the physical fitness grade dropped from 7 in the 2018 mexican report card to 6 in the 2022 edition this is because the percentage of children and adolescents who have an adequate bmi for their age decreased by 5 in children aged 511 years and 75 in adolescents aged 1219 years this grade highlights the alarming trend of increasing overweight and obesity identified in mexican children and adolescents and calls for urgent measures to halt it no nationally representative mexican data was found to grade cardiorespiratory fitness on which the global matrix grade assessment is based hence we are unable to compare mexicos physical fitness grade against those assigned by other countries with report cards in fact this indicator has the most incomplete data across countries in the global matrix which underscores the difficulty of evaluating cardiorespiratory at a national level because physical fitness is a strong indicator of health in children and adolescents it should be included in nationallevel surveillance efforts the 20meter shuttle run test has been identified as a simple test that can be used in realworld settings to assess physical fitness worldwide and should be considered for surveillance in mexico sources of influence of the indicators included in this category family obtained the highest grade showing over 60 of parents in mexico engage in adequate levels of physical activity the grade for school indicates that 40 79 of public basic education schools in mexico have resources and spaces for physical educationactivity the community and environment grade indicates mexico does not offer sufficient or safe opportunities for children and adolescents to be physically active in their community on average these grades show between 40 to 46 of children and adolescents in mexico have physical activityconducive opportunitiesenvironment in their communities this is higher than the average grades reported by argentina but lower than those reported by brazil chile colombia and uruguay in the global matrix 40 most sources of influence indicators maintained or increased their grades the school grade increased from 3 assigned in 2018 to 6 in 2022 this is because national data show an increase in the percentage of public schools with a physical education teacher the family indicator was graded for the first time in the 2022 mexican report card and sets a useful precedent to monitor the example mexican parents are setting for their children the community and environment indicator grade in this evaluation was 4 which is the same as that assigned in 2018 this indicates no tangible improvements in community environments for children to engage in physical activities were observed during this period overall these grade changes show little progress has been made since the 2018 report card in terms of providing a family school and community environment that promotes physical activity government a grade of 6 was assigned to this indicator because several government policies and programs were introduced between 2013 and 2020 and specific investments were directed at physical activity promotion efforts however no considerable progress was identified from the 2018 to the 2022 mexican report cards around these policies and programs in addition there is no information about the budget assigned to the implementation of these policies or the impact they are having other than the number of individuals they reached in the global matrix 40 mexico achieved the same grade as uruguay higher grades than argentina and brazil and lower grades than chile and colombia in line with conclusions from report cards around the world mexicos physical activityrelated policies were found to have limited comprehensiveness implementation and effectiveness the 2022 government indicator grade was 6 which is the same as that assigned in 2018 this suggests that no improvements were observed around policies strategies and investments directed at promoting children and adolescent physical activity in that period the identified strategies and investments introduced by the mexican government between 20132018 seem to be insufficient to positively impact children and adolescent movement behaviors in addition physical activity government initiatives remain disconnected and poorly articulated which limits their implementation likelihood mexico is part of the 45 of countries that lack of a national plan for physical activity all the mexican report cards issued to date suggest a national plan that strategically connects all initiatives and clearly delineates implementation responsibilities is needed limitations this evaluation should be interpreted considering the following limitations the grades are based on secondary data that was collected using selfreported instruments and in some cases using nonvalidated instruments data across age groups is limited there is no data on movement behaviors in children younger than 10 years or sports participation data in adolescents older than 14 years the active transportation data is for children older than 3 years and is not stratified by sex there is no nationally representative data on active play or physical fitness in mexico finally grades for active transportation sports participation and sleep are based on data that is not up to date thus these grades may not reflect the current prevalence of these behaviors recommendations the mexican report card seeks to inform programs initiatives and policies to improve movement behaviors among children and adolescents an extensive report including detailed recommendations on how to improve each indicator grade has been published elsewhere here is a summary of the main recommendations derived from the 2022 report card grades the physical education class should be led by a physical education teacher the recommendations by the national strategy for enhancing highquality physical education should be followed 5 investments should be allocated toward rehabilitating existing spaces to perform physical activities in the community and toward building a safe infrastructure for walking and cycling 6 a national physical activity plan that strategically connects all government initiatives and clearly delineates implementation responsibilities should be developed initiatives should be evaluated to determine how they are being implemented and what impacts they are having this is essential to coordinate the implementation and goals of all initiatives and to determine if investments in such initiatives are paying off conclusion the 2022 mexican report card grades show that movement behaviors among mexican children and adolescents are below recommended levels while opportunities to perform these behaviors are limited the grades also show mexican girls are being left behind since they have lower physical activity and sports participation than boys of the same age the small or no improvements observed in grades from 2018 to 2022 evidence the lack of commitment to address the physical inactivity epidemic among mexican children though results suggest mexico is not on track to meeting the global action plan on physical activity 20182030 goals they highlight several opportunities for improvement families schools communities and the government should consider the grades and recommendations provided here to ensure mexican children and adolescents enjoy the numerous health benefits of a physically active life data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author 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 mexican report card on physical activity for children and adolescents aims to assess the prevalence of movement behaviors and opportunities to perform them methods data on 11 indicators were obtained from national health surveys census data government documents websites and published studies data were compared against established benchmarks and a grade between 0 and 10 was assigned to each indicator results for daily behaviors we found 345 of mexican children and adolescents meet physical activity recommendations grade 3 484 participate in organized sports grade 5 35758 engage in active play outdoors grade 4 541 use active transportation grade 5 436 spend 2 h in sedentary behavior per day grade 4 and 6591 meet sleep recommendations grade 7 girls have lower physical activity levels and sports participation than boys of the same age for physical fitness we found 562618 of children and adolescents have an adequate body mass index for their age grade 6 for sources of influence we found 6567 of parents engage in physical activity or sports in a week grade 7 322533 of basic education schools have a physical education teacher grade 6 and 37 of neighborhoods in mexico have sidewalks with trees grade 4 regarding government several policies and programs aimed at improving children physical activity were launched but their impact and allocated implementation budget are unknown grade 6 discussion mexican children and adolescents engage in low levels of movement behaviors and have limited opportunities to perform such

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the role of the mass media and social networks has always been fundamental in the management of healthrelated information during this current pandemic people have been continually searching for information regarding the coronavirus infection in many cases people have unfortunately found themselves overwhelmed with news containing fake reports and misinformation which for those without the right skills can be complicated to digest this situation has generated confusion within the population and has also influenced some statements by public figures and politicians which have in turn have led to further repercussions on public opinion the general population has in good faith taken the information including fake news most relevant to their own personal situation and has used it to formulate their own interpretation of the pandemic at the beginning of the pandemic the medical community also played a role in making the situation even more confusing by giving in some cases inaccurate and sometimes contradictory indications on covid19 there have been numerous media debates about who advocated distinct conflicting positions two opposite positions could be recognized from the numerous interviews between members of the medical community on the one hand those who were inclined to spread alarming news and on the other who had optimistic ideas that supported a nonhazardous nature of covid19 a few weeks after the start of the pandemic comments from nonspecialists in infectiousrespiratory problems could be seen in the mainstream media it seemed as though the entire scientific community were releasing statements and writing articles as if they were the main experts of covid19 people were so overwhelmed by this flood of information that they did not have time to understand it correctly the massive presence in the mass media of doctors who expressed their opinions sometimes not supported by scientific evidence could be interpreted as a desire to appear rather than the need to provide the correct indications the alarming tone of some experts has caused in some cases a rush to purchase personal protective equipment and alcoholic detergents this fact partially contributed to the lack of ppe in the clinical sector and to a disproportionate increase in the prices of these products in psychologically fragile subjects an exacerbation of psychiatric pathologies 1 and determined headline stress disorder 2 has been manifested initial and overly optimistic medical statements that judged the epidemic as a simple influenza lowered social attention on the covid19 pandemic and instilled in some people conspiracy or denial ideas supported by statements by some doctors and nonmedical professionals who said its just a flu 3 the poor perception of the risks related to covid19 infection also manifested itself despite the exponential growth of infections and deaths in italy on march 21 2020 while the maximum increase of new cases was recorded 11411 people were sanctioned for not respecting the lockdown 4 in the usa the lockdown imposed to reduce contagion has been strongly opposed and its purpose diminished by comments in the media from public figures who have a greater following than the scientific community in influencing public opinion similarly the mass media in an attempt to gain visibility have perhaps unwittingly misinformed the public whenever a new experimental treatment started the beginning of an experimental treatment was reported by newspapers who reported it as the decisive discovery to combat sarscov2 thus accentuating peoples sense of security 5 moreover the search for journalistic scoops has triggered a race to find responsibility for the covid19 pandemic and has thus reduced the trust of people in the national and international institutions responsible for preserving public health social media platforms are well known for the spread of misinformation and denial of scientific literature 6 fake news has reduced the relevance to evidencebased precautions promoted by national health services 7 and perhaps little has been done to stop this virus on social networks the who has offered a whatsapp service to refute fake news but unfortunately the rapid viral spread of disinformation on social networks has been so widespread that we have in fact witnessed the appearance of attitudes harmful to health in some cases patients refused to take ibuprofen or other antiinflammatory drugs because of the erroneous idea that they could increase the chances of getting infected with the coronavirus 8 misleading information about treatment for covid19 has resulted in an increasing number of vitamin d abuse and even mass poisoning from methanol intake 9 after the lockdown in countries where social distancing and the use of face masks were mandated news of correlation between cancer and mask coverings appeared on social networks 10 the lockdown and consequent social distancing has resulted especially in those residing in highly infected areas in a posttraumatic stress syndrome characterized by anxiety sleep disturbances distress and a drop in the tone of the mood with a decrease of positive mood such as happiness and serenity and an increase of sadness or boredom 1112 misinformation and fake news contributed to the onset of ptsd and headline stress disorder cases 2 the consequences of these disorders have not only had effect in the peak infection phase but will also have future repercussions the historical importance of the covid19 pandemic is such that also in the future covid19related news will be published cyclically in the mass media and on social networks poor quality information may in the future amplify anxiety to the state of panic especially in the event of a new wave of infections people will relive the moments of the first phase of the peak of covid19 and will return to look for information to safeguard their health and that of their loved ones fake news also stimulated indignation with the consequent reaction of people for an alleged injustice the incomplete or incorrect news reported by the mass media and then reworked on social networks have also focused attention on possible errors of some hospital structures in some cases this will mean that patients will be reluctant to go to hospitals or medical centers in the fear of becoming victims of medical errors or to be at a greater risk of contagion healthcare workers subject to ptsd risk may have an additional psychological burden as they may suffer lawsuits brought by relatives of victims of covid19 who will accuse them of not having undertaken for their loved ones therapies that the mass media described as effective but which were actually experimental even an effective vaccine against covid19 could run the risk of falling victim of fake news by reducing the number of people who will join the vaccination campaigns the rapid evolution of the covid19 pandemic has not permitted immediate and certain scientific data considering this the need therefore arises that especially in the event of pandemics doctors must provide the public only with evidencebased information in a simple and shared way in order to avoid misinterpretation and misunderstanding better coordination between the medical community governments and the mass media is therefore needed to avoid the spread of disinformation through different channels limiting the dissemination of fake news and thereby better engaging the general public to adhere to correct guidelines author contributions all authors conceived and planned this paper devised the project and the main conceptual ideas moreover all authors provided critical feedback and helped shape the research analysis and writing the manuscript compliance with ethical standards conflict of interest the authors declare that they have no conflicts of interest publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

in recent years mass media and social networks have played an important role in disseminating information regarding public health during the covid19 epidemic misinformation and fake news have represented an important issue generating confusion and insecurity among the population in our analysis we investigate the role of mass media as a critical element during the sarscov2 outbreak that has influenced the public perception of risk keywords covid19 massmedia fake news public health this article is part of the topical collection on covid19

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introduction since the beginning of 2020 the covid19 pandemic and the related containment policies have modified the environment in which organized crime groups operate covid19 generated pressure for rapid and effective governance to contain the pandemic and an economic recession these changes may affect ocgs strategies thus providing an opportunity to investigate how these organizations work when dealing with global crises finding evidence on how some ocgs have reacted to the social and economic transformation introduced by covid19 is important to devise fair and effective policies aimed both at containing the pandemic and sustaining the economic system moreover it supports the fight against organized crime in a world that is in many ways different from what it used to be before covid19 and where official figures and reports are not always available in a timely manner indeed due to the transformations induced by the pandemic ocgs had greater opportunities to further infiltrate the legal economy and to strengthen their illegal governance possibly posing additional threats for governments analyzing ocgs reaction to covid19 helps also to gain greater insights into contemporary ocgs indeed two distinctive features of structured ocgs are possibly relevant in the pandemic and postpandemic scenarios on the one hand it is ocgs capacity to present themselves as providers of governance which relates to the need for effective decisionmaking induced by the pandemic on the other hand the same groups have the capacity to infiltrate the legal economy which relates to the economic crisis induced by covid19 the covid19 crisis allows investigation on ocgs that emerge as providers of governance how they do so and in what circumstances similarly it is possible to examine evidence on industries ocgs appear to target the most and their reactions to governments investments to meet healthcare costs and support their economies ocgs provision of illegal governance and their infiltration of the legal economy since the onset of the pandemic are much debated by international and supranational organizations scholars and activists nonetheless empirical studies on these topics are scant this study conducts an exploratory investigation of this issue it does so by analyzing illustrative cases of ocgs activities reported by media and international organizations at international level covering the period from january to august 2020 in doing so it provides a qualitative assessment based on reported cases and official evidence rather than on theoretical speculations no academic studies of this kind are currently available to the best of our knowledge the paper is structured as follows the next section underlines the gap of knowledge that this study aims to address by providing a survey of the few available empirical publications on covid19 and organized crime followed by a description of the various criminal dynamics investigated by this study in the broader literature on ocgs the methodological section describes the features of the content analysis at the basis of this study and the limitations of using media sources for data collection 3 the results section highlights how different types of ocgs appear to provide different forms of governance and the mechanisms behind oc infiltration of the legal economy in the aftermath of the pandemic as emerging from the analysis of identified cases then in the discussion section we analyze both sets of results in light of the theoretical literature the paper concludes by considering policy implications literature review since the onset of covid19 in early 2020 a number of scientists have investigated the impact of the virus on many volume and urban crimes in different parts of the world as well as in the cyberspace moreover several studies have considered the challenges posed by the possible reactions of ocgs to the covid19 pandemic these studies on ocgs mostly investigate various types of social and institutional vulnerabilities and they outline possible future scenarios on the basis of theoretical reasoning and the observation of macro trends such as the drop in international migration or the increase in coronavirusrelated phishing frauds however empirical studies investigating organized criminal activities are rare as the observation of ocgs actions is difficult sometime impossible in such a short period the specific topics investigated by the few available studies are quite various ranging from the provision of illegal governance to the evolution of ocgs criminal activities in terms of geopolitical focus most studies concentrated on latin american countries while only an analysis considers a different area the western balkans bruce et al examine how different forms of territorial control have been enforced by drug trafficking gangs and paramilitary groups during the covid19 epidemic in the city of rio de janeiro their results indicate that neighborhoods with a strong presence of drug gangs have had fewer casualties attributable to covid19 than have neighborhoods where the government has de facto control by contrast covid19related deaths have been higher in neighborhoods controlled by paramilitary groups bruce et al interpret their results in light of the fact that militias profits are likely more affected by restriction orders while drug gangs profits depend little on the income of the population living in the areas under their control hence the opportunity cost of implementing socialdistance measures has been higher for militias than for drug gangs the provision of illegal governance is at the center also of the study by gomez which focuses on colombia and mexico gomez reports different episodes of provision of illegal governance by ocgs in the periphery of medellín and in several areas of mexico the study underlines how criminal groups have been more effective than the public institutions in providing solution to local communities and reflects on the severe impact that this fact may have on the legitimacy of the legal governments of the two countries whether the covid19 pandemic has had any effect on the activities of drugtrafficking organizations in mexico city is instead the research interest of balmori 1 3 trends in organized crime 26114135 de la miyar et al and colleagues to proxy ocgs activities they focus on kidnapping homicides and extortions while the study does not investigate neither illegal governance nor infiltration of the legal economy their eventstudy analysis indicates no effect on kidnapping and homicides the rate of extortions also did not change during the first seven weeks of observation then it declined in weeks eight and ten the result then suggests that ocgs in mexico city maintained similar activity levels during the pandemic finally on the basis of content analysis of legal acts strategic documents academic papers media reporting official documents and interviews with police officers and representatives of civil society organizations djordjević and dobovšek have investigated how covid19 has impacted crime and crimefighting in the western balkans the authors show that in the first nine weeks of the spread of covid19 the western balkans experienced a small rise in the price of cannabis ecstasy and amphetamines which remained available by contrast the supply of heroin decreased the impact of covid19 on human trafficking in the area was instead hard to establish the foregoing review of the available academic studies on oc and covid19 indicates that empirical attention to ocgs provision of illegal governance has been marginal whilst ocs infiltration of the legal economy has not yet been investigated moreover studies analyzing ocgs reactions to the pandemic are few which leaves several issues open for exploration in particular those regarding the groups that have exploited the opportunities given by covid19 and the means they have used to provide illegal governance and infiltrate the legal economy against this background the aim of the current study is to investigate what kind of opportunities does the covid19 outbreak offer to oc and what strategies do ocgs use to exploit them while most criminal groups are relatively small flexible and engage in illegal activities for monetary gains others seek to also exercise influence on the communities of which they are part five organizations often labeled mafiatype ocgs are classic examples of the latter form of oc they are the russian mafia of the 1990s the italian cosa nostra and ndrangheta the yakuza in japan and the triads in china these ocgs do not merely exploit the weaknesses of states instead by enacting or performing statelike activities and privatizing the provision of services they also acquire a political component most powerful mexican drugtrafficking organizations neapolitan camorra as well as structured criminal organizations in brazil colombian el salvador guatemala nigeria and the united kingdom also exert control over their territories albeit to a lesser extent and with limited governance capability in their study on nonstate governance in subsaharan africa raeymaekers et al observe that crises although destructive can bring opportunities and change creating new emergent orders once the situation has stabilized this may be the case of covid19 and governancetype ocgs the medical economic and social disarray caused by the pandemic creates the possibility for ocgs to strengthen their local political influence because criminal governance relies on the relation and interaction between the state and ocgs the difficulties faced by governments in mitigating the negative impact of the pandemic may favor ocgs indeed irrespectively of its providers when governance is perceived as fair and effective it can acquire legitimacy in turn greater legitimacy brings direct benefits for ocgs and eventually supports them in their competition with legal institutions for statemaking conversely we expect to find at most few incidents referring to less stable criminal organizationscollaborations or inwardlooking criminal groups which neither aspire to nor are capable of performing forms of illegal governance in response to the covid19 epidemic besides governance ambitions criminal organizations have also the need and the capacity to infiltrate the legal economy in different ways for the purposes of laundering the proceeds of their illegal activities logistically supporting those activities and expanding their sources of income the covid19 pandemic provides ocgs with new opportunities to expand their infiltration indeed the crisis has exposed numerous businesses to a severe shortage of capital in the absence of sufficient and readytoobtain public subsidies these businesses may be at greater risk of criminal infiltration more fragile economies are those where we expect oc infiltration to be higher because less solid companies and businesses operating in the grey economy have greater difficulties in obtaining loans from legitimate financial institutions the banking system may not be able and willing to support struggling businesses because of increased systemic risk as well as their specific risk of loan default on the other hand ocgs can compensate for the higher risks because of the high liquidity at their disposal often lent with usurious interest rates and they can be more effective than legitimate financial institutions in debt recovery by trespassing the boundaries of legality opportunities have arisen not only in the private sector by relying on corruption practices and political connections oc may indeed infiltrate public procurement in order to illicitly obtain public funds specifically observation of past socioeconomic crises shows that a large number of ocgs have been able to appropriate recovery funds stimulus packages and other public subsidies for example this has frequently been the case of earthquakes in southern italy on those occasions cosa nostra the camorra and other ocgs took advantage of reconstruction works to obtain public procurements and subsidies and to strengthen their grip on local businesses and markets this is of importance because already in the first month of the pandemic the distress caused by the spread of the virus and by the social distancing measures induced the governments of several countries to plan unprecedented injections of liquidity into their economies two are the main contributing factors to the risk of embezzlement the sheer amount of disbursements and the need for rapid action the latter in particular may result in relaxed scrutiny on the use of funds urgency in fact may hinder the ability of 1 3 trends in organized crime 26114135 governments to devise and activate proper public procurement policies thus increasing the risk of criminal misappropriations in accordance with the previous literature on oc we expect to find evidence of the ability of most structured groups to misappropriate public funds on a large scale by taking advantage of the massive injection of liquidity in the global economic system induced by covid19 on the other hand we expect to find little to no evidence indicating that unstructured groups and criminal enterprises are able to infiltrate the legal economy and misappropriate of public funds indeed as observed by von lampe and blokland with respect to criminal outlaw motorcycle clubs unlike governancetype ocgs less structured criminal groups have limited capacities to misappropriate of public funds due to their lack of connections in the upperworld methodology the methodology implemented in our analysis was intended to find exemplificative cases of ocgs reaction to the covid19 situation that would serve to reconstruct how some groups have adapted to the new reality with respect to illegal governance infiltration of the legal economy and illicit appropriation of public funds data were first identified and collected through a systematic assessment of relevant information from two main sources articles by the media and reports by international organizations our assessment of pertinent cases and events published by the media relied on international national and local newspapers and reports stored in the largest available digital repositories and personalized news aggregators including the lexis nexis® metabase platform and google news we also consulted media outlets and investigative journalists sources such as the organised crime and corruption reporting project and insight crime analysis of official reports was based on public releases made by relevant organizations including interpol federal agency for medicines and health products and guardia di finanza the datagathering process began with the automatic identification and extraction of media articles and official releases using different sets of keywords and queries relating to the topic of oc and covid19 over the eightmonth period januaryaugust 2020 while media and international organizations have published many articles and reports during this time most of them are of a speculative nature or are general commentaries hence do not report tangible evidence consequently we had to filter out only those instances where actual cases were addressed in order to collect as much information as possible and to avoid double counting we further triangulated information corroborating the details of an article with information from other sources referring to the same event then a manual recognition of factual evidence was performed along with classification of the identified information into the various categories of criminal behavior examined in this study a criminal event was not always classified in a single class since an event may be related to several of the criminal behaviors mentioned above for instance infiltration of the legal economy may occur simultaneously with the misappropriation of public funds or with the involvement of illegal governance activities as result we were able to identify 29 distinctive instances of exploitation of the covid19 crisis by ocgs through illegal governance andor infiltration of the legal economy the news items and official reports analyzed were articles in english spanish italian and portuguese which were retrieved from 21 sources scanned over 85000 sources worldwide 1 the identified cases made reference to the strategies implemented by different criminal groups including the distribution of products imposition of movement restrictions price control of primary goods closure of businesses trafficking of medical and sanitary products and misappropriation of public funds the events did not distribute evenly over time since we observed more cases reported in the twomonth period from the end of march to the beginning of may limitations the main limitation of the methodology employed is associated with the nonrandom nature of the sample of identified oc activities it is well acknowledged that news media decision makers often rely on their own criteria when deciding whether or not to publish a story as well as the narrative behind it moreover media attention to ocgs may differ among countries and regions because criminal activities are perceived and reported differently in different contexts as such strategies of the medias may introduce a bias towards more sensationalist and serious crimes perhaps committed by notorious mafiatype organizations as editorial staffs might consider them more newsworthy than less serious offences perhaps committed by little known criminal enterprises related to this it may be the case that certain episodes not reported so far will be exposed in the future depending on the ability of law enforcement agencies to detect them while there is anecdotal proof suggesting that for instance the illegal acquisition of recovery funds and public subsidies may have increased in some countries there is no strong evidence to determine whether or not ocgs are able to infiltrate or to increase their governance during this period of crisis nevertheless this is not something new in the study of ocgs many authors have stressed the great difficulty of empirically assess and measure oc mainly because of its illdefinition and the endogenous error of crime reporting the first refers to the vast variety of oc definitions as some researchers concentrate on longestablish organizations some on complex and transnational groups and others on local illegal markets the second point relates to the fact that enforcement and official data will rarely reflect a comprehensive picture of oc activities even in jurisdictions where enforcement and brazil the fiftyfour news english international 1 • distribution of food parcels by gangs in cape town south africa table 1 trends in organized crime 26114135 mitigating measures are effectiveie a low level of crime related to oc could be a good sign indicating a low level of criminal activity or it could be a bad sign indicating a low rate of detection however the aim of our analysis was not to assess the extent to which both illegal governance and infiltration in the legal economy have increased or changed but instead to find empirical evidence on whether these two dynamics have occurred and if so how therefore we find value in the use of media sources for the identification of relevant cases as they provide evidence on oc activities that occur in many different places and that are often not reported to and by authorities however we avoided making claims on criminal patterns or trends as they extend beyond what we can support with the collected data and instead concentrated on the qualitative assessment of the identified articles results governance the strict lockdowns imposed by governments worldwide have sought to control and manage the health crisis these measures have resulted in an economic downturn which has imposed stress on individuals and businesses alike moreover in numerous countries the socioeconomic instability has exposed two weaknesses of governing authorities their slow and often inadequate economic assistance and their difficulties in enforcing widespread lockdowns the review of cases suggests that numerous ocgs have attempted to exploit these weaknesses to obtain maintain or increase their social legitimacy some ocgs indeed have engaged in multiple actions aimed at building consensus strengthening their control over specific territories and consolidating their bonds with local people overall from the analysis of the fig 1 temporal distribution of identified cases identified cases the means with which ocgs have tried to exert and expand their governance role during the pandemic can be classified into two broad categories first these groups have provided sustenance and facilitated access to resources that people needeg food parcels sanitary products toilet paper tissues second they have imposed and enforced lockdown measures to halt the spread of the virus the provision of different arrangements of economic relief emerged as the most frequently reported governance strategy adopted by ocgs during the first months of the pandemic the cases by the media account for different tactics such as the distribution of groceries the delivery of sanitary products but also price controls and outright cash handouts food and primary goods have been distributed by cosa nostra and camorra affiliates in the italian cities of palermo and naples sometimes exploiting fake charity organizations set up specifically for the purpose members of rival gangs in south africas capital cape town have made truce and agreed on laying down their weapons to distribute food parcels and primary goods similarly members of numerous drug trafficking organizations in the mexican states of jalisco san luis potosí veracruz michoacán tamaulipas guerrero and the state of mexico supplied bundles containing food and sanitizers to the states and cities under their influence a second type of handout has consisted in the distribution of sanitary equipment like face masks hand sanitizer and soap as done by gang members affiliated to the comando vermelho operating in the favelas of western rio de janeiro and by yakuza members in japan some ocgs in latin america have provided not only inkind contributions gang members of barrio 18 in guatemala city have suspended extortion payments while gangs in brazil have made outright cash handouts and prevented speculations halting increases in the prices of basic necessities ocg governance activities have also included the imposition and the enforcement of social distancing measures and the performance of other policing activities in some cases by threatening residents with reprisals and violence several brazilian gangs some of them belonging to the aforementioned comando vermelho have prohibited tourists from entering the favelas in rio de janeiro while also imposing the closure of shops in the morro dos prazeres citizens have been ordered to avoid circulating in groups larger than two in rocinha traffickers have imposed a curfew while in complexo da maré they have ordered churches to reduce their operating hours similarly gangs in venezuela and el salvador have enforced governmentmandated lockdowns and restricted public gatherings in the territories under their control while gang members in brazil have enforced social distancing measures in response to the governments lack of action members of the colectivo tupamaro in caracas and of mara salvatrucha13 and barrio 18 in san salvador have enforced governmentmandated lockdowns in and nearby controlled territories not all ocgs however have been reported to be involved in illicit governance activities we found no evidence for instance with respect to street gangs or 1 3 trends in organized crime 26114135 motorcycle gangs in the united states and australia or trafficking networks in any region instead we found cases of other criminal insurgency nonstate entities that did engage in governance activities fighters from the dissident 29 th front of the exfarc in colombia the taliban in afghanistan and the hayat tahrir alsham in syria have all engaged in policing activities enforcing quarantine measures and restricting public gatherings some like the taliban and hayat tahrir alsham have gone as far as substituting the government in providing basic health care services to locals by sending health teams to remote communities distributing health information and performing doortodoor temperature checks many of the identified governance activities performed by ocgs and other illegal organizations have involved blatant acts designed to ensure that the locals knew who the benefactors were although ocgs mainly seek approval and legitimacy in the territories under their control some of these activities have been directed towards a larger audience possibly in an effort to extend their reputational reach social media have played a key role in this process with several groups advertising their actions through videos and pictures mexican drugtrafficking syndicates indeed have posted images of the distribution of food parcels displaying their logo for instance the cártel del golfo printed the cdg logo on the packages it delivered or sealed them with stickers that read gulf cartel in support of ciudad victoria mr 46 vaquero being mr 46 the pseudonym of the leader of the cártel del golfo group that operates in matamoros the cártel de sinaloa the cártel de jalisco nueva generación and los viagras posted online videos in which their members distributed bags of groceries 2 in a similar fashion the yakuza have secured indirect exposure through news outlets by offering to disinfect the diamond princess 3 a cruise ship at the center of both the national and international debate concerning the pandemic infiltration of the economy analysis of the cases found in the media and official reports shows that the covid19 emergency has provided new opportunities for ocgs to infiltrate the legal economy the available evidence indicates that infiltration has occurred in the running of businesses involved in the sale of health products the misappropriation of medical funds and the embezzlement of economic stimulus packages the economic sector identified as being most vulnerable to and exploited by criminal infiltration 2 the news article by jorgic keyser torres present the same events as described in other news articles reported in table 1 they are used as a reference because they provide a more detailed description of the use of social media and other promotional activities by mexican drugtrafficking organizations however these news articles were not added to table 1 in order to avoid doublecounting issues and maintain an accurate account of the events 3 the diamond princess was a cruise ship which docked and quarantined in the port of yokohama on 4 february 2020 between 20 january and 1 march 712 passengers tested positive for the virus resulting in 14 casualties during the first phase of the covid19 outbreak was wholesale trade in medical and pharmaceutical products in this case ocgs were able to benefit along the entire spectrum of possible activities ranging from illicit ones like the manufacturing and marketing of counterfeit product to licit ones like the acquisition and establishment of fully legitimate firms or their use as covers for illicit trafficking operation pangea xiii has accounted for this reality which has been coordinated by interpol and involved police customs and health regulatory authorities from 90 countries resulting in 121 arrests worldwide and the seizure of many dangerous pharmaceuticals and medical products other cases of largescale distribution of counterfeit and defective pharmaceutical products have been reported by law enforcement agencies in several european countries such as romania the united kingdom belgium and lithuania with the latter exhibiting proven connections to romanian organized crime the fact that some seized pharmaceutical products were counterfeit suggests that there is an ongoing hybridization of infiltration in the international distribution and actual trafficking of illicit goods within the medical environment our analysis also allowed us to identify cases of misuse of public funds intended both to support medical needs and to stimulate the economic system these included cases of corruption in the procurement process whereby funds intended for protective equipment for covid19 were misappropriated and transferred to a wellknown oc member in slovenia in addition we have found a case of a massive fraud scheme coupled with money laundering concerning the supply of 10 million face masks worth €15 million in which german health authorities were scammed by criminal groups who orchestrated a complex chain of referrals between suppliers in spain ireland and the netherlands finally the analyses highlighted a case of embezzlement of italian covid19 funds in which economic relief packages valued at €45000 were awarded to a ndrangheta member through a complex scheme of tax fraud false invoices and fake names within the steel trade sector as said it is possible that the misappropriation of public funds by ocgs has increased starting after the studied period since most recoveryplans were authorized and officially implemented only in the last months of 2020 the media debate on the possibility of oc infiltration in sectors weakened by the pandemic has been vast the rapid surge in demand in specific sectors is what made them particularly attractive for speculators sectors such as the health care logistics and ecommerce all boomed due to the health crises and lockdown measures the food retail trade and cleaning services grew because of disinfestation requirements introduced in most countries waste management and funeral services expanded due to the increased mortality other sectors on the other hand became vulnerable due to financial distress these include tourism hospitality transportation beauty salons arts and entertainment and recreation nevertheless we found no official cases of infiltration to support these speculations except for the aforementioned wholesale trade of medical and pharmaceutical products again evidence may emerge in the second phase of 1 3 trends in organized crime 26114135 the pandemic when ongoing and future investigations may bring forth significant evidence discussion the analysis performed indicates that several criminal syndicates exploited the spread of covid19 in the first phase of the pandemic to show themselves as providers of governance and to benefit either in terms of power or profit from their infiltration of the legal economy there is evidence with respect to five dynamics the provision of goods in high demand the imposition of socialdistancing measures the deferral of the collection of protection payments from local businesses the infiltration of industries which the crisis made more lucrative the misappropriation of funds intended to mitigate the impact of social distancing on economies in the first eight months after the spread of sarscov2 illegal governance activities were more commonly reported by the news than activities related to infiltration of legal economy and misappropriation of public funds on the one hand this result might emerge because governance activities may take place prior to episodes of infiltration in the legal economy enforcing social distancing or providing food to communities experiencing hardship requires little planning or organization on the other hand illegal governance measures are more public and explicit than attempts to infiltrate the legal economy as the mexican cases exemplify as such they are also more likely to be reported by media and institutional reports not all forms of ocgs have been found to engage in these actions of governance in line with the theoretical expectation that the differences in activities performed by ocgs depend on their nature our empirical results provide evidence on some mafiatype ocgs exploiting covid19 to affirm themselves as providers of illegal governance in this regard cosa nostra and camorra groups in sicily and campania or yamaguchigumi in yokohama supply the population with sanitizers or food as well as proposing themselves as providers of other forms of economic support members of the comando vermelho have imposed price controls on goods in high demand because of the pandemic at the same time they have imposed and enforced stayathome restrictions on the people living in some favelas under their influence even if the popular legitimacy of the comando vermelho is often ephemeral this behavior aligns with previous cases of leaders of gangs belonging to the organization who have spent considerable sums of money on benevolent actions or provided security governance to the favelas where they are based conversely although authors such as lessing and willis show that the primeiro comando da capital originating in sao paulo provides illegal governance the group was not explicitly mentioned in any specific case this difference however may be a byproduct of the bias in the methodology presented in earlier sections indeed sources often referred to gangs and gang members in general without providing enough details on the matter hence affiliations were not always explicit and clear although the evidence presented in this papers is exploratory and criminal groups are heterogeneouseg south african gangs and cosa nostra the results indicate that support for people in need and the imposition of common rules during the pandemic have been performed mainly by ocgs with preexisting political power andor connection with the local population whether this is driven by the desire to acquire greater economic and organizational capabilities or to increase the organizations power within the community remains to be investigated by further studies by contrast no evidence was found on illicit governance enforced by criminal groups not strongly rooted in their territory before the pandemic no reports indeed account for the involvement of youth gangs outlaw motorcycle gangs and trafficking networks in forms of illegal governance in the aftermath of the pandemic this may be due to the fact that youth gangs for instance are mainly focused on their members and are not used to reaching outside their groups consequently a change in the social landscape does not drive them towards a greater role in the in the community and political environment nor pushes them to become multifunctional in reaction to the crisis these findings align with those by kim and phillips who observed a significant increase in gangrelated gun violence in buffalo new york following the covid19 outbreak and further interpreted it in light of increased strain on gang members kim and phillips argue that the pandemic has led to an unprecedented increase in the unemployment rate especially for poor individuals in the inner city which in turn has led to an increase in gun violence this dynamic clearly contrasts with the one of powerful groups organizing actions to support people in need in a showy way a similar line of reasoning may apply to outlaw motorcycle gangs and trafficking networks as these organizations already lacked the incentives and means to provide governance before of the turmoil caused by covid19 it is plausible that the provision of goods in high demand is primarily intended to strengthen bonds with the local population while discrediting legitimate institutions highlighting the inability on national and local government to help the community the endeavor by some ocgs to give visibility to their donations supports this interpretation ocgs seek to maximize their audiences thus obtaining higher returns on their investments likewise by enforcing lockdowns and stayathome orders ocgs try to propose themselves as socially legitimated governing institutions all these actions are functional to obtaining a bottomup legitimization the only exception found in the collected sample is the attempt by the yakuza to be recognized as a legitimate interlocutor by the japanese government by offering to sanitize the cruise ship blocked in yokohama nevertheless the yakuza did not achieve this form of topdown legitimacy because the japanese government refused its offer additionally expansion of governance in this turbulent period may facilitate infiltration of the legal economy in fact the two dynamics are not always clearly separated since one can accompany and serve the other infiltration of firms and the legal economy at large misappropriation and misuse of public funds and criminal governance are interconnected for mafiatype ocgs a greater consensus by the local community may turn into political support and facilitate control and influence over the local government and in turn the manipulation of public tenders in other cases the link may be simpler and more direct for instance the provision of loans at very low interest like the 1 3 trends in organized crime 26114135 ones provided by camorra or the unión tepito cartel may directly create a bond between the business owner and the criminal group which is conductive to the later acquisition by the oc group of the companys assets or share capital among the sectors that have been reported to be most vulnerable to criminal infiltration during the first phase of the covid19 outbreak the wholesale distribution of medical pharmaceutical products emerged as the main one this is likely due to the sudden increase in demand for these products which made their trade particularly profitable and possibly subject to little scrutiny by public authorities the activity of some ocgs in this sector involves the combined manufacturing and trafficking of counterfeit or defective medical devices and pharmaceuticals and the establishment of new legal firms whilst the identification of targeted sectors is important for safeguarding the integrity of legitimate economies it is essential to identify cases of firms that may be more prone to infiltration if any becomes available future studies may want to focus on the incident level rather than the structural level moreover whereas we have observed the shortterm effects the mediumand longterm ones are also relevant and possibly different as said recent anecdotal evidence suggests that the misuse of public funds by organized crime has expanded with respect to the first phase of the pandemic also because recovery plans have only recently entered into force close attention has been paid to the possibility of oc infiltration in vulnerable sectors experts on the topic expect that with the prolongation of the covid19induced crisis three main areas will be challenged by infiltration risks sectors made vulnerable by the crisis and hence with financial difficulties such as tourism hospitality and transport sectors made attractive by the crisis such as health care cleaning food and logistics and finally public funds and potential victims of fraud and money laundering although we have identified some cases of oc infiltration in the healthcare sector and misappropriation of covid19 funds we were unable to bring robust evidence in support of ocgs actual capacity to misappropriate public funds intended to support the recovery of national economies this may be due to the longterm nature of the phenomena considered and to the difficulty encountered by enforcement institutions in gathering enough evidence to carry out comprehensive investigations and operations conclusions this study has explored cases from the media and official releases on the immediate adaptation of ocgs to the spread of covid19 and to the implementation of containment and economicrelief policies adopted by governments around the world in the first phase of the pandemic among the possible changes in ocgs activities we have focused on the provision of illegal governance and on the infiltration of the legal economy since these are dynamics particularly threatening for the functioning of societies and legitimate economic systems when crises are in place the analysis of illustrative cases shows evidence on the fact that the covid19 emergency has affected the behavior of some ocgs by providing them with new opportunities to gain legitimacy and support in the community within which they operate as well as to expand and diversify their investments around the world governancetype ocgs have provided relief packages enforced social distancing and imposed price controls we have collected no evidence of trafficking networks doing the same direct evidence of ocgs infiltrating the legal economy is less abundant nonetheless it exists and it may be expected to become more visible in the medium and long term in the first eight months after the spread of covid19 there occurred episodes of ocgs trying to exploit the growing demand for medical and pharmaceutical products and to embezzling public funds these findings are necessarily preliminary and exploratory and they will have to be triangulated and verified once official statistics and additional information become available nevertheless they furnish insights into dynamics to be considered when devising anticrime and economicrelief policies during the pandemic ocg governance activities have somewhat aligned with government interests highlighting the complexity of the relation between criminal governance and legitimate state governance rather than necessarily being in immediate opposition to one another the two can sometimes align posing additional challenges for legitimate governing authorities for instance a crackdown on ocgs enforcing governmentmandated lockdowns is difficult to justify in the eyes of citizens who may deem those actions inconsistent thus further increasing the distance between them and the state in the long term however any legitimization of ocgs threatens the health of societies solidifying the position and status of ocgs in the community it highlights the failures of governments and diminishes their legitimacy ultimately making it easier for ocgs to continue their activities in the future and to swell their ranks illicit governance infiltration of the legal economy and the embezzlement of public funds should not be compartmentalized and treated as three unrelated dynamics policymakers in fact should design policies which take account of the interconnectedness among these elements carefully evaluating the tradeoffs and finding the balance among them first activities of governance and infiltration of the legal economy are sometimes similar in form because the pandemic has led to both individuals and businesses being strapped for cash some ocgs have had the opportunity to provide money and resources both to engender loyalty and to acquire shares in legal businesses second governmentissued stimulus packages entail a tradeoff between the risk of embezzlement on the one hand and the risk of infiltration and strengthening illicit governance on the other sizeable liquidity injections fiscal stimulus grants and other funds intended to accelerate economic recovery carry an inherent risk of embezzlement this risk is further exacerbated by the weakened institutions the need for swift interventions andpossiblyrelaxed scrutiny and insufficient safeguards adequate subsidies however are vital for preventing a long and disastrous recession too small and prudent interventions may leave businesses and people on the brink of bankruptcy opening the way for illicit sources of funding weakened balance sheets and grim prospects concerning future earnings indeed are fertile ground for ocgs infiltration unlike the 2008 financial crisis banks are not in distress but the inability of borrowers to provide adequate collateral and the banks 1 3 trends in organized crime 26114135 unwillingness to lend money in a highrisk environment may limit the injection of private capitals in the market ocgs on the other hand have illicit ways to coerce borrowers into paying back loans or giving up collateral to conclude governments are faced with the difficult task of striking the right balance between large and swift liquidity injections which may be misappropriated and misused by ocgs and insufficient aid which may foster infiltration and strengthen the social legitimacy of criminal groups research involving human participants andor animals the research behind this paper did involve neither human participants nor animals informed consent the research behind this paper did involve neither human participants nor animals open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the covid19 pandemic has created new opportunities for organized criminal groups and confronted them with new challenges analysis of how these groups have reacted to the pandemic yields better understanding of how they work and enables the devising of more effective counterstrategies to this end we identified illustrative cases regarding the provision of illegal governance and infiltration of the legal economy by conducting a systematic content analysis of international media articles and institutional reports published during the first eight months after the outbreak of the pandemic january to august 2020 these cases were further analyzed in order to cluster the behavior of criminal groups in response to the covid19 emergency and the means by which they tried to exploit the pandemic to strengthen their political and economic power we found that different governancetype criminal groups proposed themselves as institutions able to mitigate the burdens imposed by the pandemic by providing support to people in need and enforcing socialdistancing measures further identified cases did not provide evidence of groups devoted to the provision of illicit services and goods assuming any governance role in this respect the available evidence supports previous knowledge about organized crime cases of misappropriation of public funds and organized crime infiltration of the legal economy seem less common at least in the first phase of the pandemic the wholesale distribution of pharmaceuticals and medicines has been the sector targeted the most authors note this paper is the result of the joint efforts by all authors aa gab mj mr who designed the study and developed the methodology aa provided the introductory section as well as the review of the literature and wrote the results discussions and conclusions gab contributed to the analysis and production of results and wrote the results and discussions mj provided the methodology section contributed to the analysis and production of results and wrote the results mr contributed to the results discussions and conclusions sections all authors addressed the reviewers comments reviewed and approved the final manuscript the authors would like to acknowledge that this paper builds on the work made by the authors in supporting unodc for the report the impact of covid19 on organized crime

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introduction since the beginning of the severe acute respiratory syndrome coronavirus2 pandemic commonly known as the covid19 pandemic individuals with disabilities have experienced significant challenges one predominant challenge relates to ensuring that these individuals receive appropriate and safe support in their activities of daily living longterm care living settings have been a predominant focus during the covid19 pandemic due to outbreaks in these facilities and the subsequent alarming consequences including a high mortality rate in contrast other congregate living settings such as group homes for individuals with disabilities have received minimal attention despite experiencing outbreaks of covid19 intellectual and developmental disabilities as defined from a medical perspective in the dsm5 is characterized by an iq score between 70 and 75 and difficulty reasoning planning and abstract thinking importantly diagnostic criteria emphasize the consideration of the ability of the individual to function within the world individuals with intellectual disability may also be diagnosed with other developmental disabilities such as down syndrome or motor disabilities such as cerebral palsy which may increase their need for support for tasks of daily living in ontario a recent analysis found that those living with idd have a 128 greater risk of contracting covid19 compared to adults without idd individuals with idd residing in congregate living settings are at a greater risk of contracting covid19 and experiencing severe outcomes reasons for the increased risk of both contracting covid19 and experiencing severe outcomes experienced by individuals with idd are a combination of environmental and personal factors congregate living settings experience an increased risk of virus transmission due to the nature of these settings such as the consistent flow of support staff entering and exiting the homes moreover individuals with idd may require assistance with activities of daily living that cannot be provided in a physically distant manner medical comorbidities such as diabetes obesity and chronic respiratory disease which may increase the risk of severe outcomes from covid19 are also more likely to be present in this population at the start of the pandemic a small number of media reports began to appear regarding covid19 outbreaks in congregate living settings providing support to those with idd in ontario however it is uncertain how congregate living agencies developed and implemented their infection control policies in response to the covid19 pandemic given the potential harm associated with contracting covid19 for individuals with idd in congregate living settings there was an immediate need to understand the experiences of agencies the aim of this study was to explore the development and utilization of infection control policies by agencies supporting individuals with idd in congregate living settings during the covid19 pandemic methods this qualitative study conducted semistructured interviews with administrative personnel from agencies providing support to individuals residing in developmental services congregate living settings in ontario canada the methodological approach used was interpretive description id is an approach that explores clinical questions from an applied disciplinary grounding with an appreciation for the conceptual and contextual realm in which the target audience is positioned id seeks to understand the social and environmental forces that influence a phenomenon and use the acquired information to inform clinical practice this study protocol was approved by the hamilton integrated research ethics board research team and relationship to the topic id like other approaches to qualitative research recognizes that research is influenced by researchers so it is important to declare our lens and roles the primary investigator bdr is an occupational therapist with a research interest in individuals with idd in community settings gr formally served as senior management and as a practicing psychologist in the role of clinical director within an organization providing services to individuals with idd in a congregate living setting in ontario mf is an individual with a congenital physical disability familiar with shared support services provided in the community within ontario ef has worked with individuals with idd and has a research interest focused on infection control in congregate living settings for individuals with idd ac and lg were student occupational therapists who assisted with data collection and analysis mr and ry are disability research trainees who assisted with the environmental scan interviews transcription and compilation of the data hf served as the research assistant for the project selecting agencies an environmental scan was completed by members of the research team to identify existing congregate living agencies that support adults with idd across the province of ontario the website thehealthlineca is a nonprofit website providing information about health and social services across municipalities in ontario under the main heading of persons with disabilities the subcategory of housing and residential care was used to identify agencies one hundred sixtysix agencies across ontario were identified due to the opensource nature of the website the list of agencies was reviewed by gr because of their awareness of the ds sector and ability to identify agencies that met the research teams eligibility criteria in total 146 agencies met the inclusion criteria in the final environmental scan twenty agencies were removedtwelve entries did not provide congregate living services or did not provide services for individuals with idd and eight agencies did not provide services to adults with idd or were duplicate records data collection initially we purposefully selected agencies based on demographic data collected from the environmental scan in groups of 10 which included geographic location population and services offered however the response rate was low so recruitment was opened to all agencies additionally we found that for many agencies although their geographic head office was in one location it was possible for the agency to offer services across multiple municipal boundaries therefore the focus shifted to ensuring that the data that were collected were representative of experiential differences between organizations data were collected between march 30 2021 and may 15 2021 interviews were conducted over the online platform zoom using a semistructured interview guide questions explored participants experiences developing and implementing infection control policies and procedures within their agency prior to and during the covid19 pandemic interviews were manually transcribed verbatim by members of the research team all identifying personal information and information that could possibly identify the agency were anonymized to maintain confidentiality interviews typically involved one participant however four interviews were conducted with multiple participants given agencies preference additionally two interviews were conducted over two time points given the length of the interview one agency expressed interest in being interviewed but the representative did not arrive for the interview and did not respond to subsequent attempts to reschedule data analysis data collection and analysis occurred concurrently a subgroup of the research team was primarily responsible for data analysis the subgroup met weekly to discuss any issues with the interview process and identify issues occurring in early interviews or changes to ontarios pandemic response that required further exploration the team employed a constant comparative approach across the transcripts with the goal of identifying similarities and differences between agencies each member of the data analysis team worked independently to identify patterns across transcripts reviewing a small number of transcripts concurrently on a weekly basis to identify patterns potential categories and then themes across transcripts an id methodological approach encourages researchers to discuss research findings with individuals familiar with the phenomenon and practice context being explored during data analysis to ensure depth of description and coherence within interpretation through a process of independent scrutiny our preliminary thematic analysis involving 10 interviews was discussed with an individual familiar with the experiences of ds agencies during the covid19 pandemic but not connected to the research team results demographics of agencies and participants table 1 describes the participant and agency characteristics interviews lasted an average of 1 h and 488 pages of transcribed text were analyzed all 30 participants had direct involvement in the development and implementation of their agencys infection control policies the job titles ranged from accommodations manager to chief executive officer participants had been in their current roles for at least 2 years and approximately half had worked with their agency for over 15 years the 22 agencies provided a multitude of services extending beyond congregate living such as day programs respite services or independent supported living some participants reported that their agency had experienced infectious disease outbreaks prior to the covid19 pandemic eighteen percent reported flu outbreaks and 14 reported experiencing outbreaks during the h1n1 pandemic agency experiences with outbreaks of covid19 varied fiftyfive percent of agencies had experienced an outbreak and 45 of agencies had not experienced an outbreak of the 12 agencies that had experienced an outbreak the number of outbreaks ranged from one to dozens development of infection control policies the category development of infection control policies was used to organize data when participants were discussing the creation or updating of their infection control policies two themes emerged from the data in relation to the development of infection control policies new responsibilities and interpreting the grey areas which describes the sources of guidance and the context in which development of policy occurred from the start of the covid19 pandemic and feeling disconnected and forgotten we were lumped together which describes the relationships between public health units and ds agencies new responsibilities and interpreting the grey areas all agencies had developed infection control policies prior to the covid19 pandemic but participants viewed covid19 as different from their previous experiences with infectious diseases we had to rely on evolving information and historical practices stated participant 5 moreover participant 21 referred to their infectious disease policies as now being living documents participant 8 described the contrast in the following way i would describe it as the policy is now much more robust than it would have been 18 months ago as i say it was embedded within an emergency preparedness plan that spoke to tornadoes hurricanes electrical failures you know snowstorms and uh an outbreak of some kind of infectious disease thats obviously nowthat component has been pulled out has been fleshed out i would describe it more as operational policy now and procedure based on again the current circumstances participants relied on multiple sources of guidance to interpret public health information within the context of their setting participants identified multiple external sources of guidance when developing their infection control policies including the ministry of children community and social services and local public health units agencies also identified using internal resources such as health and safety committees and healthcare professionals on staff or seeking to hire healthcare professionals to add to their organization regardless of the common guidance established by the mccss which regulates the ds sector not all agencies took the same approach when developing or changing policies some agencies used their own discretion when considering potential risk weve found grey areas in between guidelines uh to use to our advantage um where we can but always with good intentions and again its always the balance between quality of life and risk in contrast other agencies had a stronger view of potential harms that could result from not following guidance t he organization has the liability so if we are not getting a clear and concrete answer from the ministry or they are saying that we are flexible or we can be lenient in certain areas we are not going to do that so we just went to we just relied back on our own policies and procedures and um the protocols that we put in place to keep everybody safe feeling disconnected and forgotten we were lumped together participants discussed their agencies struggles adapting general guidance to align with the characteristics and constraints associated with congregate living settings in the ds sector participants described receiving and being expected to implement guidance that was not created for developmental services agencies but instead was created for longterm care settings which are distinct congregate care settings t he challenge we have is the government and the public health theyre laying the rules down for longterm care facilities but then they just use the same rules for us and were not the same and they dont uh i dont think they worked with us sufficiently to understand who we are so they said you have to do it well we cant do it well then you are not in compliance with our requirements well okay well just do our own thing in addition to experiencing a disconnect with external government agencies and public health participants also identified a disconnect with their own ministry the mccss one participant stated the ministry were not helpful um were not helpful in a timely way t hey would come out with a memo or a guideline that was kind of would have been helpful two months before in contrast to other participants who highlighted experiences of disconnect participant 14 shared positive experiences connecting with their public health unit stating yeah our… the primary source that weve used is the public health unit so we have communicated and been in constant contact with them for the last 14 months say heres the situations that are coming up in our workplace heres the scenarios that we support within our services what is the direction how does what this clause says in the new directive apply to us im sure youre aware theres you know more than enough opinions and interpretations out there implementation of infection control policies the category of implementation of infection control policies was used when participants discussed the implementation of their infection control policies and four themes emerged its their home finding equipment and resources information overload and emerging vaccination its their home participants described how putting information into practice impacted the individuals and families they support participants emphasized the importance of the concept of home and spoke to how their agencies congregate living settings became less homelike due to the implementation of infection control policies and procedures in response to covid19 for example we always were very you know um very very focused on that its their home we work in their home they dont live in our our workplaces um so we always did really try to create a very family um you know oriented um kind of feeling and thats really changed um you know we have to ensure you know physical implementation of infection control policies • its their home • finding equipment and resources • information overload • emerging vaccination impact of infection control policies • fatigue and burnout distance whenever possible um so even i think how its affected relationships like just within their peer groups and in their homes has changed finding equipment and resources another challenge identified when implementing new policy requirements was access to new equipment one participant shared that their agency was woefully short of supplies and again adequate supplies and um supplies that would adhere to standards participants were left to problem solve the issue of personal protective equipment procurement which led to various strategies some agencies made connections with other service providers such as longterm care homes while others made connections with suppliers or retail locations to ensure a steady supply in addition to finding ppe to provide protection for staff agencies experiencing covid19 outbreaks had difficulty managing daytoday operations and meeting staffing requirements describing their outbreak situation participant 3 discussed independently working to find a hotel in the community for staff to isolate and recuperate before returning to work no so this whole thing about isolation hotels no one had even done so we ran them all wave 1 um then our numbers went down and then we ran it again as a crucial part uh we actually got another hotel in wave 2 um that we used but now were back at the the other one and um and one of the reasons we do that as well is just from a public health measure we know our workers are not able to selfisolate safely at home information overload participants discussed the large quantity of incoming information negatively impacting their ability to fully read and comprehend everything and subsequently implement the necessary changes to their policies and procedures additionally participants noted that they received lengthy updated documents but these documents often only contained small internal changes information overload i mean just as far as how even just the changes to the policies and the frequencies of those guidelines and how back and forth and rapidly thats all changing um you know a lot of people are having a hard time um keeping up with that emerging vaccination at the time of the interviews participants identified that a new component of their infection control policies would be vaccinations almost all agencies identified that both their staff and the clients they serve had received at least one dose of a covid19 vaccine participants recognized the value of the vaccine but were concerned about issues such as vaccine hesitancy and whether vaccinations could be made mandatory for staff w e were really early adopters with our vaccine policy and did a great job on that and we sent that to our lawyer we made sure we had that policy in effect before we started getting our staff vaccinated i know a lot of agencies just started doing vaccinations but we had it we had it ready to roll really early on as well in contrast to the policybased approach used by participant 15 participant 4 shared how their agency chose to focus on education and encouragement w e cant make the the vaccine mandatory we are strongly encouraging it w eve provided um a lot of information um to staff were also doing a campaign right now to encourage staff to be vaccinated um its called why we vaccinate um and um just to try and reduce some of the resistance um and some of the misinformation and myths um that you know staff are are basing um their decisions on impact of infection control policies the category impact of infection control policies was used when participants discussed the impact of the policies as well as the pandemic itself on their organization a single theme of fatigue and burnout emerged across stakeholders including individuals living in the congregate care setting their families and agency staff fatigue and burnout the experience of fatigue and burnout was apparent across participants and had a major impact on staff family members and individuals supported by agencies participants described the impact of different guidance and requirements for the general population compared to the individuals their agencies support in congregate living settings one participant highlighted the negative and unfair impact of the greater restrictions imposed on the individuals supported by developmental services agencies at both an agency and individual level s o although you know the general public is allowed to you know um with precautions go into a grocery store for example um our individuals cant even if they worked in a grocery store previous to covid um theyre not theyre they are really restricted as far as their access outside of the congregate living setting and thats something that that weve struggled with and i know a lot of developmental services um agencies have really struggled with it it does seem to be unfair and that um you know theyre theyre imposing greater restrictions from the perspective of frontline staff all participants noted fatigue one participant described the exhaustion i think the staff were all kind of hoping that we would be out of this boat by now and um so the covid fatigue and everything is really starting to set in with people um theyre done theyre hot theyre exhausted additionally participants described experiences of covid fatigue and burnout among the individuals their agencies support and their families one participant stated this covid19 has been hugely hugely harmful and emotionally draining for those parents discussion the findings of this study provide insight into the development implementation and impact of infection control policies and procedures of agencies providing congregate living services to adults with idd in ontario first at the start of the pandemic agencies had to develop and implement new policies and procedures without information that was tailored to their setting ontarios ministry of health guidance directed towards congregate living settings advised agencies to establish collaborative relationships external to their agencies as this was important for developing strong local sector plans as the results show establishing the relationship proved difficult because participants believed that the public health officials lacked an understanding of the ds sector parkes et al advocated for infectious disease responses to include multiple disciplines this recommendation is important to continue to prioritize and expand this lens beyond acute healthcare professionals physicians and nurses particularly expanding to include professionals with expertise in idd for communitybased settings the multidisciplinary healthcare team may include primary care physicians nurses psychiatrists and psychologists rehabilitation professionals and personal support workers in addition to integrating the knowledge of these health professionals in the development of public health guidance it is also important to consider the impact of public health guidance on workers providing frontline support lunsky et al explored the mental health impacts of the covid19 pandemic on staff supporting those with idd and found that one in four workers reported mental health distress the inclusion of multidisciplinary health care providers with experience working with individuals with idd would foster the creation of productive relationships between the ds sector and public health and optimize the health and wellbeing of individuals living with idd during infectious disease outbreaks a second finding is the need for public health information to be tailored to ds agencies including by respecting the human rights of their clients and the philosophical perspective of their personcentred organizational principles although the settings are described as congregate because there are multiple individuals sharing the same living space this shared space is the home of all individuals residing there the ontario human rights tribunal recently stated that human rights do not end in a pandemic while evidence strongly demonstrates that individuals with disabilities are vulnerable to severe outcomes upon contraction of covid19 as the pandemic continues policies should prioritize the balance between protection and personal safety and the importance of full participation in society focusing on choice and dignity to assist with policy development that balances public health and safety with the rights of individuals with idd in the ds sector policymakers should consider increasing the opportunity for the multidisciplinary healthcare teams supporting individuals with idd in community settings to share their knowledge during the development of health recommendations one of the barriers identified in a scoping review of responses to infectious disease outbreaks in congregate care settings supporting individuals with idd was that the institutional environment did not allow for effective infection control measures such as isolating residents who are sick from others to address this barrier it is important for public health guidance to reflect the lived experiences of those with disabilities in the community there is a need to expand public health teams within communities to include rehabilitation professionals such as occupational therapists or physiotherapists not only do rehabilitation professionals bring professional knowledge of the lived experiences of those with disabilities the rehabilitation lens also includes the theoretical framework of universal design which can be used to assist agencies and the broader community when designing guidance that is congruent with the daytoday lived experiences of individuals with idd in congregate settings from the perspective of those being supported by agencies and their families the imposition of healthbased restrictions on congregate living settings reduces individuals to being identified by where they live rather than their individual identities as citizens and participating members of their community although beyond the scope of this study participants from agencies offering other housing models such as supported independent living mentioned that those living in noncongregate living settings such as in their own apartment experienced more freedom than those living in the group homes although individuals may reside in congregate living settings it is important to recognize that they may also have opportunities such as employment in a grocery store which did not stop for others because of covid19 restrictions there is a need to recognize that covid19 has imposed new burdens on individuals with idd their family members and the staff assisting them on a daily basis unlike members of the community not residing in congregate living settings individuals with idd residing in congregate living settings are subject to rules restricting their movements and participation in community activities limitations and future directions the findings presented here have limitations interviews were conducted primarily with management of agencies understanding the perspective of frontline workers and those with idd residing in congregate living settings is important to consider and include in future research data collection occurred during ontarios third wave of covid19 during vaccine rollout further research is needed to explore how vaccination has changed the development of infectious disease policies within agencies future research should also compare the experiences of agencies supporting those with idd across canada and internationally during the covid19 pandemic conclusion the findings of this research study indicate that the covid19 pandemic and related infection control policies and procedures have significantly impacted ds agencies and staff as well as the individuals they support and their families exploration of the development implementation and impact of infection control policies and procedures of agencies providing congregate living services to adults with idd in ontario provides valuable insight and context into the current covid19 policies further research is needed to assist in addressing the gap between general public health guidance and its application to ds congregateliving environments in ontario contributions to knowledge what does this study add to existing knowledge this research demonstrates that public health guidance provided during the covid19 pandemic was not adequately adapted to congregate living settings providing support to individuals with idd this research demonstrates the need for public health guidance and policy developers to account for the implementation challenges in a communitybased setting within agencies supporting those with idd for example community agencies require guidance to procure necessary resources such as ppe and strategies to combat information overload which can be a barrier to policy implementation what are the key implications for public health interventions practice or policy this research demonstrates the need for public health to work together with professionals supporting people with idd when developing guidance and implementing infection control policies including using a personcentred approach that balances safety measures while respecting human rights and the autonomy of clients author contributions all authors contributed to the study conception and design material preparation and data collection were performed by mf ac lg mr ry gr and bdr data analysis was conducted by mf ac lg and bdr the first draft of the manuscript was written by mf and all authors commented on previous versions of the manuscript and read and approved the final manuscript

objective congregate living settings supporting individuals with intellectual and developmental disabilities idd have experienced unprecedented challenges during the covid19 pandemic this study aimed to explore the development and utilization of infection control policies in congregate living settings supporting individuals with idd during the covid19 pandemic methods this qualitative study employed an interpretive description using semistructured interviews involving administrative personnel from agencies assisting those with idd residing in developmental services congregate living settings in ontario canada results twentytwo semistructured interviews were conducted with individuals from 22 agencies thematic analysis revealed three categories development of infection control policies implementation of infection control policies and impact of infection control policies each category yielded subsequent themes themes from the development of infection control policies category included new responsibilities and interpreting the grey areas and feeling disconnected and forgotten four themes within the implementation of infection control policies category included its their home ie difficulty balancing public health guidance and organizational values finding equipment and resources eg supports and barriers information overload ie challenges agencies faced when implementing policies and emerging vaccination ie perspective of agencies as they navigate vaccination for clients and staff the category of impact of infection control policies had one themefatigue and burnout capturing the impact of policies on stakeholders in congregate living settings conclusion agencies experienced difficulties developing and implementing infection control policies impacting the clients they serve and their families and staff public health guidance should be tailored to each congregate living setting rather than generally appliedobjectif les lieux dhébergement collectif pour les personnes ayant une déficience intellectuelle ou de développement did ont affronté des défis sans précédent durant la pandémie de la covid19 la présente étude vise à explorer lélaboration et lutilisation des politiques de prévention des infections dans les lieux dhébergement collectif pour les personnes ayant une did durant la pandémie de la covid19 méthodes cette étude qualitative repose sur la description interprétative lors dentrevues semistructurées auprès du personnel administratif des organismes qui viennent en aide aux personnes ayant une did et résidant dans des lieux dhébergement collectif en ontario au canada

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introduction we have been experiencing an extraordinary period during which many parts of the world have been locked down due to the coronavirus infection this paper aims to respond to the challenge launched by science education journal and tries to offer a perspective to critically reflect on what lessons can we learn from the pandemic and how can we rethink accordingly on science teaching and its role to form the young generation in this fastchanging global and complex world reiss in his recent paper on this journal discusses crucial topics that regard the history philosophy and sociology of science that can contribute to science education in the era of the covid19 pandemic in our paper we address the theme from a deeply different perspective we will not focus on the scientific contents that should inform the curricula but we will focus on time rituals in science learning that characterize schools and science classes and that the pandemic and lockdown have unveiled and challenged the study was inspired by the rather trivial observation that pandemic and lockdown let most of the people to and experience a significant change in their perception and organization of daily and social time this happened also and mainly in schools where students and teachers had to rearrange very quickly their ways to interact and specifically the space and time structures that characterize the learning and teaching dynamics we retained that this type of change was interesting to analyse for at least two reasons when things are rapidly changing implicit dynamics and structures emerge more easily and secondly such changes can lead to new school scenarios that are worth to be anticipated we then decided to carry out an exploratory qualitative study with secondary school students aimed to investigate how they were experiencing time during lockdown and if and how the pandemic crisis was changing their rituals in learning because of our specific research background we focused on their learning in physics and mathematics and mainly investigated how time perceptions and eventual changes in learning rituals were related to the study of physics and mathematics in the design and implementation of our investigation we borrowed constructs coming from the field of sociology of time this field assumes that time as well as being a scientific anthropological and psychological construct can also be a sociological perspective investing social forms and structures in fact social actions and interactions cultures institutional and power dynamics can be analysed for their temporal structures like rituals images of the futures and relations with the past furthermore social transformations can be understood by zooming in on individuals and how they perceive represent experience and reelaborate time time perspective from a sociological perspective is a multiform lens that keeps together different scales from the individual microcosmos to the social macrocosmos that retroact on each other very often these time structures are invisible taken for granted and made trivial by habits and routines only in some historical moments do they emerge one of these occasions is the pandemic era when global time is accelerated by a natural phenomenon social institutions try to run as quickly as possible to slow down the epidemic velocity and individual time is suspended in a bubble of present during this period the dynamicsand inner velocitiesof natural phenomena social practices biological and cultural needs daily rituals and intersubjective and affective relationships are unveiled and we tend to feel a deep sense of disruption due to their emergence we will call this feeling present shock and in this paper we will try to describe it in comparison with the much betterknown psychological state defined by sociologists as future shock more relevantly for our research field we will try to show both the inspirational and operational potential of these notions to capture learning dynamics and rituals in science education the paper is articulated as follows in section 2 our research framework is presented specifically in sections 21 we introduce the concept of future shock and its elaboration in sociology its presentation is followed by the description of the state of art in science education on research themes related to the development of future thinking and foresight skills in section 22 we articulate the notion of present shock in analogy with the notion of future shock and formulate the research hypothesis that guided the empirical study special emphasis is given to the construct of appropriation elaborated in science education that has been used as theoretical lens to interpret the collected data sections 3 and 4 contain the qualitative study with secondary school students which we carried out to investigate how they were experiencing time during the lockdown period the results will contribute to unveiling how school science tends to create bubbles of rituals that detach learning from societal concerns these results will allow us also to point out how on the contrary science education could equip secondary school students with a compass to navigate the complexity and uncertainty of our fastchanging society framework 21 future shock and alienation from time in 1965 the writer and futurist alvin toffler coined the term future shock to indicate a specific psychological state basing on the popular notion of culture shock as the effect of the immersion in a strange culture for an unprepared visitor toffler characterized the future shock as the shattering stress and disorientation brought on by the premature arrival of the future the concept of future shock has been then elaborated in the 1970 book where it was characterized as a consequence not of the quantity of change but by its increasing rate it occurs in individuals who are subjected to too much change in too short a period of time to the authors the symbol of the increasing pace of change was the technological revolution with dramatic innovations in transportation and the rising of computers as supermachines that were occurring in those years however the great engine of technology has knowledge as its fuel and it is to the velocity of knowledge development that the construct of future shock primarily refers indeed the cognitive and psychological distress of future shock happens to be the result of an overstimulation offered by society with its technological societal and economical changes which cannot be processed cognitively and rationally by individuals the authors name this condition as information overload that forces people to adapt to a new life pace to confront novel situations and to process information at a far more rapid pace than was necessary in slowlyevolving societies of course the examples of technology and the vision of future to which toffler and toffler referred in their work have dramatically changed since the 1970s however the core of their argument ie the increasing pace of change of knowledge production and application remains valid nowadays making the future shock even more dramatic than it was half a century ago elaborating on the phenomenon of future shock sociologists started to investigate its impact on human beings identifying some sociological problems that were emerging in modern societies in recent years the german sociologist hartmut rosa coined the expression of society of acceleration to describe the current society and its relationship with the perception of the future according to rosas analysis modern life is subject to three major dimensions of acceleration technical acceleration social acceleration ie changes in the institutions through which we bring order to our lives and acceleration in the pace of life ie the general sense and experience of time and deadlines on a daytoday basis technical acceleration is central to rosas argument and is indicated as the main driver indeed in contemporary societies humans do not often interface directly with the natural world they live in a technoecology it is such technoecology that in contemporary societies mainly drives global dynamics another central issue of rosas argument is that social institutions like political and educational systems despite changing are not able to keep up with the pace of technological transformation because of their inertia things seem to change very quickly but in fact they happen without any strong sense of directionality this perspectiveless state leads to what is called frenetic standstill events remain episodic in both individual and collective experience and because of the lack of directionality nothing remains the same but nothing essentially changes the impact of frenetic standstill on individuals appears as a sense of fragmentation or dispersion of the sense of self following rosas argument identity becomes situational the individuals reaction to social acceleration … seems to result in a new situational form of identity in which the dynamism of classical modernity characterised by a strong sense of direction is replaced by a sense of directionless frantic motion that is in fact a form of inertia on encountering such a sentence no one especially those who care about education can remain indifferent indeed we have all been surrounded by this imperceptible feeling of breathlessness disorientation and disharmony caused by the coexistence of different misaligned times on one hand we have the time we need for reflection taking care of ourselves and people around us learning figuring out solutions for pursuing social equity or addressing global challenges like climate change on the other hand we see the world running innovating competing exchanging at an impressive velocity and creating continuously new and unpredictable scenarios and needs that leave behind all other requirements this misalignment leads to a sense of fragmentation in our experiences that can lead to frustration but also forms of burnout to describe this fragmented and meaningless perception of happenings rosa refers to the distinction between two german terms that as walter benjamin recognized can be used to talk about episodes of present erlebnissen and erfahrungen erlebnissen are episodes of mere experience when we live through them they seem neverending and leave no trace in the memory because of this feature rosa calls them longshort experiences erfahrungen are instead experiences that leave a mark and contribute to building our identity when we live through them they seem to pass very quickly but leave a trace in the memory rosa calls them shortlong experiences a century ago benjamin complained with some concern that we were approaching an era rich in erlebnissen and poor in erfahrungen rosa stresses that today we are experiencing a world of shortshort episodes time seems to escape from both the sides it goes fast and it does not leave traces in the memory consequently the episodes of present remain alien we are not able to appropriate them and make them ours in the sense we are not able to turn them into events that are significant for us this is the phenomenon that rosa calls alienation from time alienation is another central concept in rosas view and following marx it indicates that state in which people pursue objectives and follow practices that no external agent or factor oblige them to do but they do not feel like doing or want to do alienation from time rosa continues is strictly interrelated with alienation from others and as we saw alienation from self in fact our identity and sense of self derive from our actions experiences and relations and from how we situate them and ourselves in the social and material world and in their spacetime fabric frenetic standstill the sense of directionlessness situational identity alienation from time and contraction of the present are all manifestations of the future shock that acceleration produces struggling with the future in the society of acceleration and uncertainty has important educational implications since it is one of the main issues for the young generation the youth perceive the future as a threat instead of a promise without future horizons the present is lived as completely oriented toward seizing the moment sniffing out every opportunity and keeping open all possible scenarios the present appears fragmented in a plurality of events that have no real temporal connections between them alienation from time and difficulties in young people in projecting themselves in their future are confirmed and illustrated in a 2015 eurobarometer survey the educational literature on students perception of future has been discovering an important nuance in such perception a sort of duality in futures thinking the young may see their personal future as positive and in their own hands but they view the national and especially the global future as hopeless frightening and completely outside their influence to face these issues educational authoritative reports highlight the need to search for teaching approaches that enable to develop foresight and anticipation skills for example oecd elaborated an educational framework based on the aar cycle aar cycle implements the core idea that responsible actions emerge through anticipatory and reflective processes in fact aar cycle is an iterative learning process whereby learners continuously improve their thinking and act intentionally and responsibly moving over time towards longterm goals that contribute to collective wellbeing in the cycle the first phase anticipation is related to foresight skills since anticipation implies that the learners exploit their abilities to anticipate the shortand longterm consequences of actions understand their own and others the intentions and widen their own and others perspectives the second phase action implies that learners take action in the present reflection is the third phase in which learners improve their thinking in order to reach a deeper understanding and better actions toward wellbeing these competencies if combined in cycle are supposed to develop faster both agency and transformative competencies the goal to search for a futureoriented approach is an emergent theme in science education although still underexplored science education is interested in foresight for several reasons firstly future views being utopian or dystopian are connected to science and technology secondly science education more and more explicitly can become a very locus to promote erfahrungen and guide students to appropriate their time and develop the sense of self thirdly many foresight or future thinking skills that are needed to navigate the society of acceleration and uncertainty can be easily related to scientific thinking and developed through the learning of science we are referring to foresight or future thinking skills such as scenario thinking systemic thinking thinking beyond the realm of possibilities action competence managing uncertainty and complexity and creative thinking the incorporation of stem activities in the curricula that could foster the development of foresight or future thinking skills is the main goal of the two extensive projects in science education the first project has been carried out in australia by paige and lloyd who developed an educational approach that integrates a future dimension into science learning to enable students to develop a broader futureoriented perspective that can impact on many aspects of their lives they stress the necessity to identify and envision alternative futures that are more socially and environmentally fair and sustainable the second project has been developed in europe the research group of physics education of the university of bologna together with colleagues from the university of helsinki and an icelandic ngo studied how school science can equip and empower secondary school students to face uncertainty and contribute meaningfully to their own and global futures they coined and operatively defined the concept of futurescaffolding skills that are skills to construct visions of the future that support possible ways of acting in the present with an eye on the horizon most of this study has been framed within the erasmus european project i seeinclusive stem education to enhance the capacity to aspire and imagine future careers the educational approach is described extensively in levrini et al tasquier et al and branchetti et al as an outcome of the project four teachinglearning modules were designed and tested every module was built on a different futureoriented scientific issue a scientific and futurerelevant topic which is at the core of current societal debates and may be of interest to students the topics of the four modules were climate change artificial intelligence carbon sequestration and quantum computing the modules were designed on the assumption that science is an impressive source of knowledge for thinking and talking about the futures indeed the epistemic practice of building predictive models and causal structures for explaining and foreseeing natural or social phenomena is constitutive of science science has developed various models of causality as well as the linear and deterministic models of newtonian mechanics twentieth century science has elaborated more and more sophisticated probabilistic models quantum physics and the science of complex systems are rich sources of concepts such as space of possibilities future scenarios projection instead of prediction uncertainty agent feedback and circular causality which can be suitable for development into skills for thinking and talking about the future as well as for developing citizenship skills the implementation of the i see modules was monitored and led the researchers to progressively identify define and refine operational markers able to describe the change in students perception of the future through the modules and identify futurescaffolding skills these studies pushed us to ask how the teenagers were experiencing the period of lockdown and isolation within i see we touched upon the great difficulties encountered by young people in imagining their futures and we closely touched how challenging and demanding it was to guide them to develop futurescaffolding skills as a followup of i see we aimed to investigate if and how students perception of time was influenced by the quick changes induced by the pandemic and to create a new baseline to reflect on the role of science education in supporting the young as they navigate through fastchanging spacetime structures present shock and time reappropriation the covid19 pandemic besides many aspects of our lives has deeply transformed the time structure that regulates our social and individual rhythms this situation shows aspects that are different from those that characterize the society of acceleration first acceleration has during pandemic a natural origin and because of this its pace of change is a matter of fact nature is following its own evolution all our cultural systems have been following the virus diffusion and are searching to identify its biological epidemiological and clinical features in order to slow down the pandemic contagion and save the health systems and societies available scientific mathematical and technological knowledge has been applied and the production of new knowledge and technology has been accelerated as far as possible when a pandemic is occurring just like now science and technology are chasing behind the natural evolution of the virus in order to produce a vaccine and to elaborate recommendations for governments policymakers and other institutional panels science and technology are fighting against time and many forms of uncertainty for example even if international guidelines for data reporting and sharing have been developed even before the covid19 pandemic science is fighting against the lack of national and international standards for data collection and sharing against the overproduction of fake news or pseudoscientific rumours that continue to influence people and in many countries against the slashing of resources in research and public health systems also methods of interaction with policymakers take time this race by science shows the dramatic dilemma for scientists who have to balance the urgency of a situation requiring immediate responses with the time required by scientific methods which is intrinsically longer regarding policymaking governments and municipalities are required to make immediate decisions in conditions of emergency to flatten the curve and try to limit the risk of collapse in the social and health systems even in the most virtuous cases we have observed policymakers and governments who were reluctant to learn immediately from precedent experiences part of the problem is that each government is focused to take into account also local political and cultural peculiarities according to which decisions are based on different priorities or values as well as on different conceptions of risk when decisions have to be taken so quickly the risk of asymmetric effects that favour some categories over others is very high the search for an equilibrium between conflicting interests objectives subjects institutions and their various dimensions takes time but this time is also the ground of democratic systems and social cohesion in many countries all over the world people have been requested to lock down and stay isolated and act as responsible citizens from our houses we have been eyewitnesses to a worldwide phenomenon and under a careful look dynamics and practices that are usually invisible can be discovered in such special social periods we can see and learn for example how science works how our societies are organized how our institutions and leaders operate and what values have been prioritized by our leaders we can also learn about the role ascribed to science and technology in our social contexts and what role is designated to knowledge and education however whilst we have the chance to observe these complex structures emerge our daily time appears suspended we are searching for new rituals new habits and new priorities that can normalize and control the time of our daily practices thus the time structure of a society during pandemic is rather special outside the public and social world is running as fast as possible to contain a disaster inside in the places where lockdown was disposed the private and daily world is grappling with a new form of slowness the society of acceleration leccardi argues has reduced the time of everyday life to trivial and repetitive rituals that have slowly disappeared from the attention of our societies this time instead includes a precious embodied dimension where time is linked to concrete spaces and is made up of gestures and acts that follow multispeed rhythms in daily lifetime the private and public world can be kept together and in the risky fragile and global world the future of our societies and the planet depends increasingly on everyday rituals in italy lockdown at national level lasted about 2 months and during that moment we felt the urgency to investigate how teenagers were experiencing their time as we will describe in detail in the methodology section the match between the data we were collecting and the feeling that we were perceiving during lockdown led us progressively to formulate the following hypothesis the lockdown period led people and students in particular to the rediscovery of daily time and the recognition of its enormous value also as a locus to take agency and build empowering visions of the future compared with the precrisis period the sense of alienation from time gave way to the feeling of time reappropriation we were all reappropriating the meaning of our daily rituals and perceiving a new sense of directionality although the future was still invisible we perceived that we are witnessing an epochal transition we called this general feeling present shock and we decided to carry out a survey aimed at testing such a hypothesis that is testing whether students were really reappropriating their time and how such reappropriation looked like appropriation is a key word in the learning sciences and in science education when used in these fields the term is borrowed from scholars in linguistics and education and used to link disciplinary learning with a special personal engagement that makes learning authentic bakhtin in linguistics defines appropriation as follows it a word becomes ones own only when the speaker populates it with his own intentions his own accent when he appropriates the word adapting it to his own semantic and expressive intention prior to this moment of appropriation the word does not exist in a neutral and impersonal language but rather it exists in other peoples mouths in other peoples contexts serving other peoples intentions it is from there that one must take the word and make it ones own when we apply the quotation to science learning and refer appropriation to a concept like force temperature or entropy appropriation implies productive learning including deep conceptual understanding but it also involves a reflexive process of populating scientific discourse with personal intentions purposes and tastes that allow a student to embody scientific discourse and concepts in a way that is authentic and personal this usage of the term appropriation stands in explicit contrast to the more typical connotation of appropriation of scientific discourse that would imply that students learn to speak like scientists or use words in the formal register of physics without necessarily developing personal meaning on the contrary when students appropriate a concept they begin to speak an authentic language which has meaning and relevance for themselves as well as being respectful of consolidated knowledge the construct of appropriation has a long history in the research literature tracing back to vygotsky after bakhtin it was use and developed for example by rogoff sfard and prusak and sfard in science education it has been operationalised as a theoretical construct in a study that concerned secondary students reactions to an extended teaching intervention on thermodynamics the analysis of data collected during that implementation demonstrated how students not only made progress in learning the disciplinary content of the teachinglearning path but also made progress making the material relevant in a personal sense a bottomup finegrained qualitative analysis of students interviews and classroom discussions allowed the authors to identify five discursive markers for operatively deciding whether students had appropriated the scientific discourse of the unit the discourse of students who spoke their own language and revealed appropriation presented the following features being a developed around a set of words or expressions repeated several times and linked together so as to express a personal idiosyncratic signature idea with respect to a physics topic b grounded in the discipline ie the signature idea was used by the student to understand scientific concepts in the sense that it was used as a tool for focusing on pieces of disciplinary knowledge selecting and reassembling them to make sense of the specific concept c thick ie the signature idea involved both a metacognitive dimension and an epistemological one d nonincidental ie the signature idea was expressed in several activities throughout the students classroom experience not just in one interaction or in the moment of the interview e carrier of social relationships ie the signature idea allowed the student to play a specific role in class discussions and this role was acknowledged by others in the classroom community the markers indicate that appropriation is a multilayered process where the students take an idea and elaborate it according to their own interests and testes and coherently use the idea to position themselves with respect to disciplinary knowledge with respect to others and with respect to their own personal story of who they are as a person and a learner in the next sections we show how the markers of appropriation inspired a way to investigate how teenagers are now grappling with the present shock and whether they are searching for strategies to appropriate their time during lockdown the survey will show that the markers were helpful for outlining articulated profiles of time management however in order to unpack the relevance of the markers we needed to refine the structure of the appropriation markers with further submarkers coming from the literature in sociology of time that we introduced above in particular we needed to interpret the personal conceptions of time that emerged in terms of their relations with daily life rituals the sense of agency on ones own time and the sense of time directionality such submarkers allowed us to stress that whilst the alienation from time leads to a sense of identity fragmentation and identity to be situational time reappropriation during lockdown leads to a reappropriation of the self and of the others that is a reappropriation of the sense of what disessa calls intrinsic identity that form of identity that concerns patterns inherent in our varied and distinctive ways of interacting with the world including the social world this is not surprising since in moments of deep change we are all required to deal with the need to realign our selfperception as agent or receptors of change producers of sensemaking as well as the need to refine our norms and criteria to manage ourselves with respect to others in this sense identity is at issue the link between appropriation and identity is widely described elsewhere here we simply stress that when in our analysis of students discourse we saw terms and expressions regularly repeated by the students that appeared idiosyncratic and thick then we assumed that those pieces of knowledge mirror aspects that can be related to intrinsic identity methodology the study was carried out to answer the following questions a how are secondary students experiencing time and what if any knowledge are they using to grapple with the changes in its pace b how does the learning of science contribute to supporting the students to rearrange their daily lifetime rituals more specifically does science learning support students to deal with global concerns such as pandemics and climate emergency and to grapple with quick changes in the time structures of our complex and fragile risk society a survey was designed with an exploratory and piloting nature it was not meant to provide comprehensive answers but to pave the way and lay the foundations for further wider and more focused rounds of investigation for this exploratory survey we chose the tool of extensive individual interviews and a qualitative approach for the analysis we then decided to focus on a special group of secondary school students we selected students at the end of their secondary studies close to making their own university choices and particularly interested in science the students that we involved in the survey had attended extracurricular courses on advanced stem topics organized by our department in january and february 2020 we chose these students to maximize the probability of encountering teenagers who refer to or use scientific knowledge and competences to deal with the current changes in this sense we considered them particularly suited for breaking the ice hewing the theme and providing tips to refine tools and aims for further stages of the research nine students agreed to be interviewed they were all attending the same type of school a liceo scientifico scientificoriented secondary schools in italy but they did not know each other since they were from different schools which were also in some cases in different cities the protocol of the interview is reported in the annex it includes 23 questions articulated in two main sections in two main sections section 1 questions about the ways they were experiencing the lockdown section 2 questions about their perception of time in the first section the questions concern the changes they perceive in their everyday life the role they ascribe to school and school science the role of science they see in the current social and political debates the channels of information they use the kind of individuals they consider experts and the type of trust they feel in the second section the questions regard the role played by past present and future in their thinking when they have to deal with difficulties andor to make personal choices their perception of time in the present daily life their perception of the future in the short mediumand longterm period and their perception of the scale of the pandemic in the big history and its effects on social transformations we used three main criteria for the specific formulation of the questions the questions had to reveal where existing futurescaffolding skills the questions had to foster a relaxing interaction aimed at development of thinking and generating knowledge in the interaction the questions had to make the interview a significant moment during which the students were guided to elaborate their own experience discover possible ways to grapple with its novelty and participate in the social debates the interviews were conducted in videoconference by ol ss and gt each of them lasted between 1 h and 75′ they were produced during the lockdown period in italy from late march to early april 2020 the interviews were audiorecorded and transcribed the data was analysed through methods inspired by grounded theory which we generally apply in the analysis of extensive interviews or classroom data the analysis was performed through explicit back and forth dynamics from data to their theoryoriented interpretation in accordance with our second research question the interpretation is also oriented toward concrete support for teaching this combination of bottomup and topdown processes from data to theoretical interpretation and vice versa was carried out through a series of systematic debriefing and triangulation meetings among all the authors of this paper the overall process comprised four phases overview of data the first phase corresponds to an overview of the whole corpus of data to identify a sensitizing idea that could guide us in data immersion the compass we initially used to navigate the corpus was inspired by the notion of future shock we examined the data by identifying which pictures of the future emerged and looking for analogies between the futurescaffolding skills and the skills that the students declared or revealed for managing such a period of emergency at the beginning this phase was very frustrating since the answers to the questions on the future were the poorest part of the interview and the way students talked about their strategies and feelings in this period were very weakly linked to the categories we had elaborated and refined in our previous experiences they either mirrored a general tendency to deny thinking about the future or reproduced the wellknown distinction between a concrete and positive image of a personal future and an uncertain one sentences like this pandemic will finish and i will go back to my normal life my plans have not changed i am just thinking about ways to get through this period as well as possible or im looking forward to starting university and getting on with my life were very frequent it soon appeared clear that the pandemic did not act significantly at that level and that the future was not the most interesting theme or time dimension of the interviews although we found this result initially surprising we then realized that it was coherent with the sociology of time and with our hypothesis that the pandemic acts more on perception of the present in particular the most satisfying moment of the first phase was the discovery that maybe students were grappling with the issue of appropriating or reappropriating their own present time starting from this intuition we fleshed out as a sensitizing idea the hypothesis that our appropriation markers could be revised and used to capture how students were grappling with time and in particular how they were trying to stay consciously in the present of their current experiences this intuition moved us forward to the second stage of the analysis construction of a shared grid for data analyses the second phase corresponds to the elaboration of the analytical grid we started from our appropriation markers and revised them so as to fit with the theme of the interviews the change of context from appropriating a physical concept to appropriating time naturally required a significant adaptation of the five markers which were then transformed into the following sets of questions used in the interview a is there an idiosyncratic idea about time management which the students focused on in the interview b does the student use disciplinaryschool knowledge to manage their time c is the core idea thick ie is the student able to develop herhis core idea in a consistent way throughout the interview does shehe appear aware of it d is the idea nonaccidental ie does the interview suggest that the core idea is grounded on experiences and reflections that are not only suggested by the contingency of the interview e is the idea a carrier of social relations andor does it allow the student to see herhimself situated in society two further sets of questions have been formulated with the explicit aim of reminding us to remain focused on the theoretical orientation of the analysis and the relevance of the results for teaching a what contribution does the interview make to help refine the idea of present shock and to build a baseline framework on students strategies to managing fastchanging space and time structures do a sense of slowness directionality and the importance of daily rituals emerge do they see their role in social cohesion and as agents of history b what contribution does the interview make to help us build an argument about the role of science education and the role of disciplinary knowledge to equip the students with knowledge and competences to manage fastchanging space and time structures the questions have been slightly reformulated throughout the process of analysis to make them significant for all the interviews and effective in capturing the most interesting points of the students discourse immersion in the data and profile construction the third phase was the core of the analysis represented by full immersion in the data the application of the analytical grid allowed us to outline students profiles six complete profiles were produced by selecting the most different interviews three interviews have been used as sources to comment and discuss the results before applying the grid to the whole corpus we started with two interviews to check whether the questions made sense and were easy to apply to make this check at least two people independently of one another listened to the interviews and highlighted the most interesting excerpts directly on the transcripts then two or three researchers confronted the highlighted sections and having agreed on the selection the sentences were compared with the questions and positioned under the question they were judged to best answer we quickly realized that the set of questions was effective in capturing all the highlights and for organizing them in an apparently faithful profile of the student at least two researchers worked on each profile when all the profiles had been drafted we realized that the initial formulation of the questions left room for different interpretations and this compromised the comparability of the profiles we then organized an alignment meeting to share an increasingly operational elaboration of the questions the meeting resulted in the following list of instructions a to search for the idiosyncratic idea check if there are words that the student repeats more frequently to talk about herhis way to manage time which cannot be ascribed to the interviewer if so select the core sentences where the keywords are structural and try to paraphrase the core idea with a catchy sentence that can help transmit the essence of the idea as a final step select from the interview all the excerpts that show if and how the idea has been elaborated throughout the interview b in order to check whether the core idea is related to disciplinaryschool knowledge focus on all the parts of the interviews where the students talk about subject matters or science distinguish between the sentences where shehe mentions contents the sentences where epistemological or methodological aspects are used or mentioned and finally sentences that refer to the theme of science and society andor to the role of experts c in order to check the thickness of the concept search for its consistency within the interview and where possible its nuances and articulation throughout the interview we are making the hypothesis that inner consistency of the discourse can reveal a form of awareness and depth of thinking d consider that accidentality refers to the fact that students discourse does not touch upon identity aspects but has arisen spontaneously under the stimulus of the interview questions thus in order to check and measure nonaccidentality check if the student mentions or refers to experiences and thoughts from outside of the interviews be careful to remember that we are all experiencing an extraordinary period thus distinguish in the interview between two types of accidentalitycontingency that the student can show the accidentality of the interview and the contingency of the pandemic e in order to check if the core idea plays any role to position the student in society describe the social network mentioned by the student and describe the eventual links between the core idea and the type of interpersonal relations and social positions in which shehe feels immersed now or in the future on the basis of this operational grid we finalized the extended profiles which can be downloaded here double check of the profiles and results once we had all the profiles we compared them first with each other and then against our theoretical framework the comparison was carried out along three axes i the pictures of time that emerged from the interviews j appropriation its nexus with identity and its contribution to defining present shock k the role attached by the students to science and its learning regarding the first point we operationally focused mainly on the first part of the profiles as for the appropriation analysis we operationally referred to a summary on the five markers application as well as to the first extra question which concerned specifically the contribution of the appropriation analysis to the sense of present in order to unpack the appropriation markers we applied three further criteria coming from the sociological literature finally in order to compare the roles that science knowledge and education played in students approach to managing the crisis we operationally focused mainly on the second part of the profiles as well as on the last extra question from there we identified indicators for the next agenda for science education the results from this phase are presented and discussed in the following sections results students conceptions of time in the pandemic era the first result concerns the emergence of an articulated and stratified picture of students perceptions of time from the profiles three main conceptions of time can be recognized time as an opportunity to immerse yourself in experiences time as agenda and time as an empty container to fill we use this macrostructure to present the students and sum up the core idea that they expressed in their interviews in order to protect anonymity students are identified by pseudonyms but gender distinction is maintained 411 returned time as an opportunity to immerse yourself in experiences four of the six students in question see the current time as an opportunity to immerse themselves in their experiences let us start with chiara the core idea of time that emerged from her interview is in the motionless and suspended time created by the pandemic one can find ways to manage the oppression of the present with new activities to control time and by escaping with the imagination toward fantasy scenarios chiaras whole interview revolves around her perception of velocity of time before the coronavirus crisis she was really full of things to do time passed very fast now the time has slowed down and it is much slower actually it is also more difficult to face she feels that time is a little suspended she never really feels it moving the stillness of the present is coupled with a sense of anxiety caused by everyone around her talking about the pandemic i feel very surrounded by all this the news every day my mom my dad my friends who talk about it she perceives strong differences between her personal time and the time of society from which she feels detached they all move superfast actually they all seem much more on it everything outside happens very fast chiara has found two main ways to manage her motionless and oppressive present state firstly she enriches her daily routine with a lot of new activities from the interview it is clear that these activities are not only new rituals with which she fills the empty container of her time but new distractions to control time the other way she has found to manage the oppression of the contingency is mental escape which makes the present lighter and more liveable she often loses herself in a fictional world in which she is not surrounded by reality and this is not only something she likes but something that really helps her also watching movies in this moment its nice to see the dystopian ones or science fiction it helped me a lot to have read to have seen some apocalyptic films as well as chiara alessandro expressed in his interview the idea that the pandemic has allowed him to recover time which free from external commitments is a time given back for alessandro this time is a great opportunity to immerse himself in personal intellectual experiences moreover it is also a good opportunity to look for new ideas for reflection on social issues with two goals to acquire new knowledge but also and mainly to broaden his own points of view alessandro is deeply aware that building thinking tools is not an immediate and easy process it takes time the organization of the day must certainly consider school commitments relaxing activities and social conversations with friends but above all there is room for that free time which is no longer a counted time there is the possibility to choose how to use these slices of ones time and for alessandro it means having the possibility to immerse himself in personal intellectual experiences latent intellectual interests such as an interest in philosophical thought could reemerge and be developed the returned time is therefore not the counted time of the clock but a mental time the time necessary to cultivate that thoughtfree from other thoughts it reemerged in this period the interest in philosophical thought i already had it i just didnt have slices of free time and now its coming out quite disruptively im glad because there are all the conditions necessary to bring out the interest … now i can slice me up some time and dedicate myself only to that and i like it even more because i can immerse myself in it returnedliberated time is that time to stop and rethink oneself both as regards the personal dimension linked to ones own interests dreams and expectations for the future but also as regards the social and political sphere the third student gabriele also took this moment as an opportunity to immerse himself in his thoughts in the interview he expresses the idea that the right way to spend his restored time is looking for the essence and the truth of what is happening looking at history as a source of knowledge about mankind the invariant what does not change in order to pursue progress and improve the human condition he refers to two kinds of time internal time to be filled in the right way with passions reflections and trying to find the right nonroutine routine and external time the time of mankind which is linear deterministic concerning what lasts what does not change man is always the same man always does the same things technology changes changes there is incredible progress but in the end it is always man it is always him from what he perceives as a privileged position gabriele observes that this pandemic period removes the veil of maya obliging people to become aware of all the critical issues and difficulties that have always existed the virus simply showed the problems we are observing on a social level but we were already in a relative moment of crisis but it has always been like that that is there have always been simply that before they were directed toward different topics the virus brought nothing new except this state of quarantine it does not create any sense of upset in gabriele since he experiences the crisis as something outside of him the right way to spend time is therefore exploring the surrounding world by searching for the essential by finding invariants that are not scratched by time then we have laura like alessandro laura describes time as a personal nonroutine construction which has to be invented and reinvented by fitting together as many activities as possible the better i can fit things together the better i can manage them the pandemic caused a drastic change in her daily life organization from rhythmic days organized around extraschool and outsidehome commitments to the problem of finding other activities to fill the time the quick change imposed by the pandemic led her to lose at the beginning any sense and conception of time im mostly losing the concept of time completely that is not what day it is today for example i dont have the perception of when it was a week ago after an initial moment of great bewilderment the awareness that it was necessary to react emerged at first it seemed like resignation and then she found a way to rearrange her time by allowing old passions to reemerge like playing music reading novels and mastery of astronomical topics the implications of the drastic change that she complains most about regard the fact that many outofschool commitments like a course on particle physics at cern planned for the immediate future have been cancelled they represented certain moments sort of milestones in her path toward the choice of university the solution she found to replace these activities is to read and study the syllabus of university curricula and try to imagine herself in the future attending those courses i think yes it gave me confidence and certainly comfort to see what i could do i have to say that looking at the degree courses or things like that is making me excited so all these aspects show that time for laura is neither something awarded by external or social constraints nor an empty container to fill but a personal construction built by fitting and cultivating personal interests and passions time as agenda one student giorgia describes her way of grappling with time which is rather different from the students we have discussed so far giorgias interview revolves around the following core idea on time i have to try to understand how to manage time better and try to take advantage of this time that now i have time for giorgia emerges as a personal agenda that she creates in accordance with external commitments to optimize her personal path and pursue her goals lockdown is seen as an opportunity to have empty slots that must be capitalized upon she feels as though she is in a crucial moment of her life where she has to choose the university degree course and she feels the pressure of this choice especially in this period i have to think about my university choice and its not easy because anyway maybe i choose the wrong option that is it seems that if i make this wrong choice this will be my future giorgia is very focused on adhering to her daily routines whilst she does not follow any political sanitary or public debate school and homework instagram youtube and apps to chat with friends help her to routinize very concrete activities youtubers and influencers also help her to accept also empty times there is a woman a youtuber who has been a kind of comfort because she said that it is normal that in this situation there are moments when in fact you would not feel like doing anything the core idea appears strictly related to her selfconfidence and trust that if she focuses on her training and if she works hard she will be able to reach her goal to achieve a leadership position i always imagined myself i dont know in what area i dont know how i dont know where but that i was able to reach a high level in what i was doing i have always seen myself since i was a child perhaps very probably also very influenced by the films i saw and various things just i who enter my office as a boss manager of what im doing so my job my great goal is to be able to reach that level a similar position is expressed by caterina and dario two of the three students we interviewed without outlining the profiles caterina and dario are also very focused on their education and in addition to capitalizing on the extra slots to improve their calculus skills in order to become researchers in physics they are also taking the opportunity to learn to strengthen their resilience or concentration skills time as container only one student stefano expressed the implicit idea that time is a container that must be managed by filling it with engaging and enjoyable activities daily time is perceived as an ordered rhythmic organization of school commitments and social activities with friends stefano is particularly interested in scientific subjects and his identity is strongly related to his being a very good student extremely talented in physics because of this time perception the covid19 crisis did not create a deep sense of disturbance his world and his temporal organization are still as before the crisis populated by rites of daily life that involve his school commitments the study of physics and videochatting with friendsthis activity is aimed both at sharing leisure time and helping each other in scientific disciplines and any technological issues related to distance learning the main change in his time management produced by the covid19 crisis concerns a sense of emptiness and a sense of urgency in particular regarding the sense of urgency he stresses that the crisis showed that time should not be wasted and priorities can be changed the priority of things has changed if before i did a b and c now i have realized that c is more important and therefore i dedicate more time and above all more energy before i would say okay ill do it tomorrow now its not tomorrow i have to do it now the rituals and hobbies allow him to feel protected from the external world and external suffering he does not follow any social debate since he finds them painful and he and his friends prefer to take the situation more lightly we take the situation as a game but not a game intended as fun also because according to instagram there are many jokes a lot of jokes about this situation that is happening probably i also didnt really understand what it is and therefore we dont feel this great need to say oh my god this is happening so we dont feel this great need to remember it even when we are together with friends when we are together it should be a moment of relaxation … comparison of profiles the threepronged picture of time perceptions that emerged from the profile mirrors the debate between substantivalism and relationalism that can be traced back in the history and philosophy of physics the distinction of spacetime as containers or as relations indeed seems to capture the two more general ways that people use to think of and to talk about time in students conceptions we can recognize in the words of stefano the echo of the newtonian conception of time as a container that provides an external organization to the multiplicity of the events all the other students appear to be agents of their time and their words echo the view of space and time as a set of relations a social or personal construction elaborated to organize experiences and provide them with an order of succession from our bottomup analysis we found two different ways to conceive the relations that create the sense of time an order of succession to be ascribed to activities and organize daily time according to that agenda and a time generated by immersive experiences in personal thoughts the first is the case of giorgia whose time is created by planning her activities so as to capitalize on experiences and select the most relevant for her future for the other four students the sense of time is created by immersion into personal reflections that can involve different plans imaginative sociopolitical and intellectual this last remark highlights the fact that the overall picture emerging from students profiles is more nuanced than the threepronged macrostructure we fleshed out such richness needs a different lens in order to be captured in the next section it will be inspected through the lens of appropriation that will zoom in on the nexus between time perception and identity appropriation of time and its nexus with identity after the presentation of students conceptions of time we can now focus on the appropriation profiles that emerged from the application of appropriation markers as lenses to read the transcripts the most important result is that the application of markers resulted in five complete profiles of appropriation and one incomplete profile all the markers were satisfied for five students out of six indeed only stefano the student who had the picture of time as a container did not appear as an aware agent of his time and encountered a little difficulty in the metacognitive or reflective questions his interview indeed looks like a collectiondescription of small activities or examples referring to his private life he never answers a question at a level of metareflection and never refers to abstract concepts to reflect on time and the effects of this crisis instead in his answers he always refers to local examples or contingent cases related to his families and friends for example when he is asked to answer this question are you currently feeling pressure or are you experiencing accelerated times coming from outside he answers as follows then the most important thing concerns perhaps the work of my parents who however since said slowly that is the work of my parents the work in general stefano is also the student who least perceived any change his daily rituals created a bubble that protected him from the external world and in this bubble there is neither directionality nor any relationship with the accelerated time of social institutions that are running after the virus and trying to control it the latter dimension is perceived as belonging to the adult realm in all the other cases students appear not only able to express their core idea of time but they were also conscious that they were experiencing a special moment that will be written in the history books and that could be turned into something important for them for example giorgia said in this moment of suspension the desire to be able to achieve something of personal success is even higher than before so maybe it also gives that sense that is i selfinfluence my future alessandro said i was struck by the fact that in a very short time the pandemic has completely changed the cards a little bit in general my perception of long time has been a bit modified in perceiving how an event can also quickly enter and rewrite a page of history… the five complete appropriation profiles show that the conception of time outlined in the interview and reported in the previous section are very personal authentic and genuine the conception is deep in two senses it is conscious and nonaccidental furthermore it implies that a special role is ascribed to knowledge as well as to positioning within a social network as we reported in the introduction within the future shock induced by the society of acceleration alienation from time is argued by rosa to be strictly interrelated with alienation from others and alienation from self the copresence of the five markers in most of the students profiles shows that also the process of appropriation the contrary of alienation indicates that time appropriation is deeply connected with reappropriation of the self and of the relations with others in our case also the role of disciplinary knowledge is stressed as a fundamental component of this complex process that relates time appropriation with identity formation in the following sections we start showing the connection of markers a c and d with the sense of the self and then we move to unpack the marker related to the social dimension marker b is unpacked in the next section when we make a special focus on the role that science education plays or should play to equip the young to manage these deep social crises and transformations in order to unpack the first set of markers that is the idiosyncratic idea expressed by the students consciously and in a nonaccidental way we apply three key concepts that we pointed out from the literature on sociology of time the importance and the role of daily life rituals the sense of agency on ones own time and the sense of directionality by rereading students conceptions of time through these key concepts the first finding we obtained is that all students conceptions are centred on personal daily life rituals in fact all the students express a revived need to stay in the present of their daily experiences and to become first of all agents of their personal daily lifetime the reorganizations of the daily life rituals are ways through which the students exert their agency to maintain an unchanged sense of self that is to maintain their intrinsic identity stefano giorgia and gabriele were very keen on sustaining that the crisis did not really change their intrinsic identity this emerged in their way of considering the lockdown as an opportunity to strengthen those routines or thoughts that they feel most essential and to legitimize them even further for example by awarding these rituals more time and more centrality in their daily life chiara alessandro and laura perceived the change in a more significant way and had to change their rituals to preserve their inner sense of the self chiara had to invent new ways to control time and the new sense of oppression that she felt alessandro took the opportunity to widen his views and discover new perspectives from which society could be observed finally laura had to change profoundly the activities that generate her sense of time and mainly her sense of self before the pandemic sociological studies stressed that social acceleration had diminished the time of everyday life to trivial and repetitive rituals that slowly disappeared from the attention of our societies from our students profiles it appears that the conception of time during lockdown centralizes rediscovering daily time and its value for all the students except stefano daily rituals are also the way to reappropriate a deep sense of directionality that was lost in the era of future shock giorgia is aware that before the pandemic we were in a moment of frenetic standstill where change was somehow apparent she feels the need to distinguish between frenzy and real development actually i hope we understand the fact that this busy life didnt lead to so many developments in the end in this state at least i have always felt it like this everything was always the same always constant over the years this situation and this block could give the opportunity for a change for giorgia time has to be directional and change has to be real the past has to provide hints and the present has to be exploited in order to become agent of ones own future lockdown was an opportunity to rediscover and strengthen the directionality of time and make effective plans for the future also for laura the student who most perceived the present shock lockdown pushed her to search for a new sense of directionality her personal organization collapsed and important events that she perceived as milestones for her future were cancelled thus she had to reinvent her daily routines simply to reappropriate a sense of directionality directionality became for laura a process of cultivating her passions and exploring society to recognize how and where she can nurture her interests now and in the future alessandro has consciously recognized the frantic arrest as a change but not as a problem an opportunity to seek a new sense of directionality given by immersing in ones own intellectual interests directionality for alessandro as for laura is offered by authentic intellectual thoughts or passions and by the sense they produce for them both directionality becomes lost in routines and experiences aimed solely at developing mere techniques on the contrary passions and sensemaking give directionality turning experiences into erfarunghen laura uses her passions also to project herself into the future gabriele is also looking for a nonroutine routine in his case the search revolves around trying to fill time in the right way unlike alessandro and laura gabriele is not experiencing any sense of deep change and he is filling the day with the same interests activities and reflections he lives in a sort of bubble that is in continuous interaction with the outside world and from which he observes society that at this specific moment has become aware of critical issues that have in fact always existed but which are now impossible to ignore the pandemic confirmed to gabriele his idea about the dynamics that propel society people are capable of looking only at their own interests at what is important in that moment neglecting most of the time the true sense of things however he recognizes that for the world the pandemic is a tragedy and hence he retains that people have to learn and find a sense of directionality by looking at the past people can extrapolate many teachings in order to achieve progress better action in the future than in the present chiara also perceives a sense of directionality in society but not in her private life she manages the slowness and stillness of the present by immersing herself in bubbles of entertainment and imagination but perceives the directionality of the historic moment where people are working hard to obtain a cure for the virus and in general to manage the crisis as we already stressed above chiara feels as though her daily life is totally detached from the directionality of society and for her personal life the only thing she can do is escape within fictional scenarios this is the dimension of present shock that chiara is experiencing a clear separation between the velocity priorities and actions of the world outside and those of her daily life to sum up this first part of the analysis of students conceptions of time aimed to unpack markers a c d through the lenses coming from sociology we can stress two results the idiosyncraticity appears not only in the choice of the rituals but also and mainly in the multiple forms assumed by the sense of directionality directionality and more generally the glance at the future are indeed the intrinsic aspect of time that mostly provides actions with a meaning as we widely stressed in our framework on future shock when directionality gets lost time gets fragmented and identity becomes situational the second result concerns the relation that emerged between daily life rituals agency and directionality such a strict relation indeed creates a strong demarcation line between the time of private life and the time that characterizes social phenomena this is a result that challenged our expectations and one core aspect of the daily life rituals as they are described in the sociological literature we expected to find in daily life rituals the manifestation of the nexus between the private and the public realm between the personal and the societal dimensions instead this extreme period of change revealed at least in our group of students the serious gap that exists between these dimensions this result allows us to unpack marker e related to the social dimension also with respect to such a marker students profiles of appropriation show interesting commonalities and diversities this first commonality is that all the students perceive a significant misalignment between personal time and social time this is very evident in chiara and gabriele chiara feels the oppression of the difference between the stillness of suspended time of her present and the speed of society that moves superfast gabriele recognizes a different time structure of the personal and social time the internal time is seen as made of right nonroutine routines whilst the external time the time of mankind is linear and deterministic and he thinks shows a sort of human inertia oriented toward avoiding any change in stefano and giorgia the personal time creates a sort of present bubble that protects them from the external storm only laura and alessandro seem to perceive the need to maintain the nexus between the personal time of their experiences and social time the realignment of their daily routines implies a dialogue with social changes and engagement with societal transformations alessandro said i hope that this present time has made us understand the fragility of our whole system and of our way of life one of the reasons why we sometimes think that everything cant change is stable destined to last looking at it from a single point of view is because maybe there has never been a moment like this in which the whole system has broken down and so i hope that we can all become aware of the fact that it doesnt necessarily have to go on as we have done until now in my opinion we wont come out from this moment with the answers but already changing the point of view of millions of people is a big step both laura and alessandro are very interested in social debate and unlike gabriele they reveal a proactive mood toward the possibility of acting on society and taking some agency in societal transformations this proactive mood was slightly more evident in aldos interview aldo was the only student who explicitly mentioned the concept of responsible citizen as the nexus between personal and social realms and the way individuals can take agency to contribute to a better world however despite the references to society by alessandro laura gabriele and aldo the students profiles highlight that the personal dimension is as we might expect the most relevant aspect in the period of isolation lockdown gave students the opportunity to rediscover and cultivate interests that had been neglected due to lack of time and to strengthen friendships and relations within the family furthermore it also emerged that for this group of talented students ambition and trust in personal abilities were important ingredients in managing the crisis and exploiting the restored time in our interviews we saw only a few signals about the need to reflect on the role of individuals as responsible citizens and active agents in this global fragile and complex society in accordance with the literature on future dreams and hopes refer more to personal success than to a significant improvement of society as a whole even when society represents an important focus of attention the perception that it can be changed and that each of us can be an agent of such changes seems in general faint this is an important aspect where science education can insist and play a fundamental role to sum up the appropriation analysis of the interviews confirms some intuitions we had about the benefits of reading the present as a moment where people feel deeply the need to reappropriate their time here we took the markers we identified for describing the appropriation of a physical concept like temperature and extended their application to a more elusive concept like time in the original approach the construct of appropriation allowed us to unpack how science learning could lead to a broader sense of learning and contribute to developing identity here the application of our markers to time allowed us to recognize the elements characterizing time appropriation as foundational to rediscover or maintain ones own identity and contribute to overcoming the sense of situationality moreover we recognized in the diversity both of the rituals and of the sense of directionality the inner idiosyncratic aspects that regards the intrinsic identity the multifaceted sense of directionality included both personal directionality given by a plan or by the search for sense and the collective directionality that society can find when huge events happen to upset the status quo however the distinction of the two realms and the sense of agency related mainly if not only to the first open up the main problem that we will address in the next section and that we can anticipate as follows school and in particular science school has a very weak if any role to form any sense of social agency despite all the recommendations and the claims our study confirms that school science and school education is mainly focused to prepare students as future professionals than as social actors or responsible citizens the role of science education the third axis we consider in comparing the profiles regards the role of science education such an axis allows us to unpack marker b and mainly to analyse the implications of the study both on school science and on the research in science education the data we consider here come from those parts of the profiles designed to answer the following questions of the analytic grid does the student use disciplinaryschool knowledge to manage their time what contribution does the interview provide to build an argument about the roles of science education and disciplinary knowledge in equipping the students with knowledge and competences to manage fastchanging space and time structures firstly the six students profiles highlighted a polarized attitude toward the scientific knowledge acquired along their personal school path for three students out of six school science represents a bubble in which they can feel at ease and that protects them from the toughness of reality for example for stefano who is a very good student studying science and math and solving scientific problems are sources of intellectual pleasure also scientific disciplines in their application are a source of escape they help him to manage internal times to eliminate anxiety by distracting from the external problems stefano does not use science as a key to read and interpret reality and the contingency it creates isolated bubbles that like a game provide pleasure enjoyment and social relationships also chiara found in science a way to make sense of the present reality in particular the analysis of the epidemic curve from a mathematical perspective reassured and helped her to rationally manage the present however chiara is aware that in this moment understanding the science behind the epidemic is important but even more important is the need to personally manage the anxiety of the moment by escaping with her imagination even giorgia finds a refuge in school science mathematics and physics are the subject matters that she prefers and their being in her mind ahistorical and certain knowledge allows mathematics and physics school classes to restore a sense of normality classes continue just like before the pandemic and the teacher does her best to maintain normality and do her classes as she did before lockdown giorgia thinks that this is possible because of the inner character of mathematics and physics as unchangeable invariant ahistorical and certain disciplines thanks to these aspects mathematics and physics school classes give giorgia a sense of peacefulness even in such a strong moment of crisis despite the interest of those students toward science their engagement with the discipline is not a key for interpreting the current debates for the other three students school science represents a baseline knowledge to be refined with hints and reflections coming from other sources andor to be enriched with extracurricular activities school science can set out somehow an initial mindset concerning the kind of methods and discourses that belong to science for example gabriele holds scientific disciplines in high regard because they provide the basic knowledge that allows him to distinguish the person who holds the knowledge from the person who speaks to gain visibility or simply for the sake of speaking school science allows him to decide who can be trusted or not because it helps him to recognize when a discourse is well constructed and grounded again alessandro recognizes the importance of scientific thought in this time of emergency and the role of scientific experts however he stressed that the study of scientific disciplines should provide not only knowledgewhich may not be sufficient to enter into the merits of technical issuesbut also the tools of scientific thought that allow him to move between the plurality of data and information and can act as a filter lastly for laura physics and astrophysics are a deep passion on which she consciously builds her sense of time by allowing her to project her imagination toward the future indeed scientific methods and the science mindset are for her a way to rationally manage the present contingency and follow scientific controversies however this level of scientific awareness does not come from school science which is completely removed from her mind but from extracurricular experiences we remind that the students selected for this study represent a sample of students chosen for bootstrapping the best information available about science education at school all of them were highly motivated students with a strong interest and passion for science so much so that they had decided to attend a demanding extracurricular course at the department of physics and astronomy also because of the choice of sample for the study the results have clearly revealed how much school science is missing an important educational opportunity in the pandemic era indeed the patterns highlighted above related to these two roles played by school science can be seen as an expression of misalignment between the science taught at school and the science needed to deal with a risk society for these students school science is completely detached from society science they are taught remains isolated in a school context at best it influences their ways of thinking about their personal career or creates a space for enjoyment and selfaccomplishment their ideas of science do not provide them with effective lenses to interpret social dynamics triggered by the pandemic crisis even in the cases of students who refer to society and pose problems with a mindset that could be interpreted as scientific they do not recognize them explicitly as skills developed at school another idea that emerges from students discourses is an epistemological belief that science heralds certain facts and indisputable truths that reassure and help them to make sense of the world this could be ascribed to the almostunivocal focus of science curricula on newtonian paradigm where determinism linearity and prediction are the keywords the whole language of classical physics constructs an epistemological scaffolding to imagine the history and the future deterministically as a linear progress toward an increasingly better world nevertheless at the basis of the risk society there is a very different paradigm ie the complexity paradigm where different temporal patterns and models of causal explanation are conceptualized as we already mentioned when we presented the project i see in the background the science of complex systems could be a very rich source of concepts like scenarios feedback deterministic chaos and agent which could play crucial roles to open up new ways to conceive the scientific enterprise and its relationship with socially relevant themes like a pandemic the concept of uncertainty could also be revalued in science education not as something negative but as a concept that opens up a variety of possibilities for everyones imagination another important concept that complexity has at its core and that could be valued through education is the idea of system indeed the recognition of the multiple levels that constitute a system allows the students to make explicit these levels and their relationships also about reallife contexts a system can be investigated not only for its levels but also for the dimensions it covers and impacts developing rich discussions in the classrooms about these aspects could be important to foster competencies for analysis of complex issues a stem curriculum should include all these themes if we want to value science education as a way to prepare the young for this fastchanging society that appears more and more fragile and at risk discussion in this paper we borrowed an idea from sociology and used it to reflect on the role that science education can play to enable the young to navigate a fastchanging society we started from the notion of future shock as characterization of the society of acceleration and observed that the pandemic has induced a different type of shock which we define as present shock the aspects that we took into account for characterizing this quick change are the fast disclosure of time structures that were invisible before the pandemic or diminished as trivial rituals during a pandemic the global time is accelerated by a natural phenomenon and we have become witnesses of the dynamics of social institutions trying to run as quickly as possible to slow down the speed of the epidemic at the same time during lockdown our individual time was suspended in a bubble of present that had to be redefined in its inner rituals on the basis of this idea we carried out an empirical qualitative study to investigate how teenagers with a strong affinity for science were experiencing this moment of change and what could we learn from them both to better define the idea of present shock and to reflect on the role of science education our study focuses on six interviews and has a merely exploratory and piloting character the type and number of the students makes the sample very particular but also in our opinion particularly rich for paving the way for further wider and more specific rounds of investigation we carried out a fourphase analysis of the six interviews first we searched for the sensitizing concept by navigating the whole corpus of data and we were able to identify that perception of future was not the way to encode the time structures that the students were enacting to manage the current situation this phase led us to recognize instead the potential of our appropriation markers and we designed our analytic grid accordingly the dichotomy between alienation from time and time reappropriation became the crucial aspect for highlighting the difference between future shock and present shock the application of the appropriation markers led us to organize the data into six comparable profiles which we analyzed and discussed along three different axes students conceptions of time appropriation and the nexus between time conception and identity and the role attached by the students to science and its learning each comparison led us to recognize inner but important aspects of students discourse first of all we saw that the macrodistinction between space and time as containers and space and time as relations which characterizes the debate on space and time in physics and philosophy is always effective in capturing the main idea of time however we also saw that we needed to refine the lens to restore faithfully the richness of students discourse we then used criteria taken from the construct of appropriation elaborated within science education to capture authenticity in disciplinary learning the application of our markers allowed us to argue that appropriation is in fact an effective counterpart of alienation as alienation from time is strictly interrelated with alienation from others and alienation from self also the process of time reappropriation during the era of pandemic is strictly related to the appropriation of self and of the relations with others in order to unpack markers a c and d we used criteria taken from the sociology of time the role of daily life rituals agency on ones own time and directionality these criteria allowed us to connect the conception of time with the notions of intrinsic and situational identity more specifically we were able to identify that students conceptions of time were built on daily lifetime rituals that the students enacted to maintain an unchanged sense of self in some cases the maintenance of intrinsic identity implied simply allocating more time and priority to routines activities or thoughts regarding authentic interests in other cases it required a deep and somehow dramatic rearrangement of daily rituals independently of the individual differences our analysis shows that within moments of deep change the time structures that contribute to forming identity become particularly evident during a period of lockdown each of us more and more explicitly dealt with the need to realign selfperception as agents or receptors of change and sensemaking producers and to adjust the ways we relate with others this complex process requires the recruitment and application of a great deal of knowledge but also we saw specific time structures identity process is indeed regulated by rituals and routines that shape our reflective project made up of selective processes exploration of options and decisionmaking processes moreover the application of our markers to time allowed us to recognize two further elements in the time rituals that are related to identity and specifically to a deep sense of identity that is not situational the sense of agency and directionality the discovery of a multifaceted sense of directionality makes this aspect deeply related to intrinsic identity and shows where the young tend to act to reappropriate their future and the sense of their learning and their actions this aspect is mainly the most relevant finding of the study that pointed out a serious detachment between a sense of personal directionality and of social directionality students discourse revealed a special dialogue with oneself and others specifically we discovered that the others in students discourse are friends parents teachers and influencers there is not that chorality that one could recognize as a sense of collectiveness of society this revealed a break and deep detachment in the personal and the social dimension the rules and paces that characterize daily life personal rituals on which they feel to be agents appear completely different and detached from what the students perceive to be the dynamics of society some of them use science to build and stay in their own spacetime bubble protected from society the social directionality even when it is perceived or recognized is far from their agency as for personal directionality one aspect emerged that we found deeply problematic students manifested in the interviews a strong urgent and authentic need to immerse themselves in deep personal experiences but in several cases this need was completely detached from what the school offers or requires them to do this remark moves us on to the final comments the school emerged from the interviews as a source of normative and soothing rituals that even in a pandemic era can offer certainties and a sense of normality this is particularly true for the classes of mathematics and physics ie the favourite subject matters of these students they are seen either as sources of ahistorical unchangeable knowledge whose teaching cannot be affected even by such a deep crisis or as a solid baseline on which personal or social interests can be nurtured by extracurricular activities from this picture and from our analysis we see that science and stem teaching could play definitively at least three more relevant roles firstly time and space are scientific themes that scholars from all other fields use to interpret complex phenomena occurring in our global and fragile society it is a missed opportunity that science and stem curricula do not dedicate special attention to them in terms of language structures and epistemologies elaborated to conceptualize and manage them time and space are intrinsic interdisciplinary themes that if properly addressed can turn knowledge into fundamental competencies for the twentyfirst century in our previous projects the debate on space and time was at the basis of the design of our materials on relativity and in the project i see we designed modules to point out the causal structures that science elaborated for managing uncertainty and the future in terms of forecasting or foresight as we mentioned the science of complex systems is an impressive source of fundamental concepts for consciously navigating the risk society we are now working within the project identities to refine these modules and exploit their interdisciplinary character secondly in this fastchanging society it is more and more urgent that science education prioritizes research studies aimed at evaluating its role in developing students identities this study shows that this also implicates revision of the curricula and teaching materials so as to boost specific rituals training routines aimed at developing technical skills but also and mainly rituals explicitly aimed at breaking down routines and fostering immersion in personal interests and thoughts this operationally means designing materials and enacting teaching strategies that enable students to play with their own ideas and make them feel that their personal search for sense is legitimate and welcome also within the classroom culture in our study on appropriation we argue how materials built on multidimensionality multiperspectiveness and longitudinality can support classroom dynamics that foster appropriation now we have unveiled new time properties that should hold in order to foster identity formation these properties link school and extracurricular activities regarding the role of daily rituals and the centrality of a sense of directionality thirdly school science has to thoroughly redefine its institutional role within society not only the knowledge but also the rituals that science teaching tends to boost seem to produce the effect of creating bubbles in a society characterized by a communication that enhances polarization and echo chambers the school system plays a crucial role and can make the difference school must open up to society and enact processes that whilst contributing to forming students as active and responsible citizens also transform itself as an institution this is the main direction that this study will follow in our next research studies within two horizon 2020 projects the seas project and the recently approved fedora project we are indeed in an extraordinary period and must not miss the opportunity for deep social transformation toward a more human rational equal and sustainable society where there is space and time to take care of ourselves others and the planet section 2 questions about the perception of time 13 do you feel more like a present past or future person that is to manage a moment of change do you find greater stimulustrustrefuge in the study of history and in drawing lessons from the past in the management of present contingency or in imagining dreaming future scenarios can you explain in what sense 14 has this crisis changed your perception of the small time of your daily life if so how do you feel empty times times of boredom of waiting in your daily life do the days seem longer 15 do you feel acceleration times or pressures from the outside that influence your daily life 16 has this crisis changed your perception of the big time of history if so how 17 do you think the world will emerge better or worse from this crisis how 18 will the future of society benefit from this or should we expect a worsening compared with the future that was expected before the crisis 19 has this crisis changed your perception of the mean time of your education 20 we give you three different time horizons the end of the lockdown the end of school and the end of university how do you imagine yourself at these times in which scenarios or in which global socialpoliticalcultural contexts do you imagine yourself 21 do you think this moment of emergency will affect your future what future how 22 do you think this moment of emergency will affect society as a whole if so in which aspects 23 how would you define your mood in front of this great change 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 conflict of interest the authors declare that they have no conflict of interest appendix 1 annex interview protocol we are going through a very particular moment that is changing among many other things our daily lives the ways to deal with our relationships and our perception of time

the crisis due to the covid19 pandemic led most people all over the world to deal with a change in their perception and organization of time this happened also and mainly within the educational institutions where students and teachers had to rearrange their teachinglearning dynamics because of the forced education at a distance in this paper we present an exploratory qualitative study with secondary school students aimed to investigate how they were experiencing their learning during lockdown and how in particular learning of science contributed to rearranging their daily lifetime rituals in order to design and carry out our investigation we borrowed constructs coming from a research field rather unusual for science education the field of sociology of time the main result concerns the discovery of the potential of the dichotomy between alienation from time and time reappropriation the former is a construct elaborated by the sociologist hartmut rosa to describe the society of acceleration in the era of future shock the latter represents an elaboration of the construct of appropriation that the authors had operationally defined starting from bakhtins original idea to describe the nexus between physics learning and identity thanks to the elaboration of the notion of time reappropriation as feature of the era of present shock the study unveils how school science instead of preparing the young to navigate our fastchanging and complex society tends to create bubbles of rituals that detach learning from societal concern

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background substantial improvements in human health and significant increases in average life expectancy are major achievements of civilization over the past two centuries 1 life expectancy at birth in england and wales has doubled from about 40 years in 1850 to more than 80 years in 2013 2 future life expectancy is projected to increase across 35 industrialised nations with a median increase in life expectancy at birth of approximately 3 years for women and 4 years for men in the uk between 2010 and 2030 3 many adults however spend a substantial portion of their lives with latelife morbidities and decreased sensory motor and cognitive functioning which may reduce their quality of life 45 more than 80 of the population of england and wales aged 85 and above report having a disability and 50 require care or help with daily activities 6 recent data suggest that healthy life expectancy in the uk has decreased between 2008 and 2016 7 nevertheless some individuals experience very little functional decline in old age and rate their health as good or excellent 8 a greater understanding of the factors associated with good health may help increase longevity and healthspan ie the length of time that a person lives healthy 9 the health effects of lifestyle factors such as smoking 10 diet 11 excessive alcohol intake 12 and physical activity 13 are well documented however the number and type of covariates that have been adjusted for in previous analyses vary widely 14 making a systematic comparison of risk factor associations across studies difficult few studies have jointly examined sociodemographic psychosocial lifestyle and environmental factors a review of multivariable models examining determinants of selfreported health concluded that most factors except for age sex and education were examined in only one or a few studies 15 in addition research has often focused on predicting mortality or disease incidence instead of overall health status despite its potential to provide insights into the factors associated with increased healthspan the uk biobank study provides an unprecedented data resource to investigate determinants of health and ageing trajectories one of its strengths is that the data collection was not merely focused on established predictors of health and disease such as lifestyle but also included relevant nonmedical factors such as social isolation and loneliness as well as road traffic noise and ambient air pollution 1617 the aim of this study was to explore predictors of health status from a wide range of potential risk factor mechanisms more specifically we examined how health status was associated with sociodemographic characteristics and psychosocial factors lifestyle factors and environmental exposures both independently and jointly we also examined as a secondary aim whether there was evidence of similar associations between these factors and reporting a longstanding illness and selfrated health methods study population the uk biobank is a prospective study of over 500000 uk residents aged 3773 at baseline recruited between 2006 and 2010 details of the study rationale and design have been reported elsewhere 18 briefly individuals registered with the uk national health service and living within a 25mile radius of one of 22 assessment centres were invited to participate at the baseline assessment participants completed questionnaires and were interviewed by nurses to provide data on sociodemographic characteristics health behaviours and their medical history a small subset of participants completed repeat measurements first revisit of participants living within a 35km radius of the assessment centre at stockport england between 2012 and 2013 second revisit as part of the uk biobank imaging study 19 between 2014 and 2019 participants consented to use of their deidentified data see additional file 1 table s1 for the uk biobank data fields used exposures multiple explanatory variables were considered based on their likely relevance to public health in terms of modifiability and potential for risk stratification representing a wide range of potential risk factor mechanisms sociodemographic characteristics we considered individuallevel sociodemographic characteristics including age at baseline assessment sex ethnicity highest educational or professional qualification collegeuniversity degree education to age 18 or above but not reaching degree level general certificate of education advanced level general certificate of education advanced subsidiary level or equivalent national vocational qualification higher national diploma higher national certificate or equivalent other professional qualifications education to age 16 qualifications general certificate of education ordinary level general certificate of secondary education or equivalent certificate of secondary education or equivalent no qualifications and gross annual household income we also included the index of multiple deprivation for england which is a smallarea level measure derived by government from data on income employment health and disability education skills and training barriers to housing and services living environment and crime 21 higher values on the index reflect greater deprivation psychosocial factors loneliness was assessed using two questions do you often feel lonely and how often are you able to confide in someone close to you individuals who received a sum score of 2 were classified as lonely 22 social isolation was assessed using three questions including yourself how many people are living together in your household how often do you visit friends or family or have them visit you and which of the following leisuresocial activities do you attend once a week or more often individuals who received a sum score of 2 or 3 were classified as socially isolated 22 lifestyle factors smoking status was assessed using two questions summarising current and past smoking behaviour individuals who responded yes on most or all days or only occasionally to current tobacco smoking were coded as current individuals who responded smoked on most or all days or smoked occasionally to past tobacco smoking were coded as former individuals who responded no to current tobacco smoking and just tried once or twice or i have never smoked to past tobacco smoking were coded as never alcohol intake frequency was assessed using one question about how often do you drink alcohol response options included daily or almost daily three or four times a week once or twice a week one to three times a month special occasions only and never sleep duration was assessed using one question about how many hours sleep do you get in every 24 hours values below 1 h or above 23 h were rejected and uk biobank asked participants to confirm values below 3 h or above 12 h body mass index was calculated as weight divided by height squared weight measurements were obtained with a tanita bc418 ma body composition analyser standing height measurements were obtained using a seca 202 height measure physical activity was assessed using the international physical activity questionnaire short form 23 specifically we included data on the number of days per week spent walking engaging in moderateintensity physical activity or engaging in vigorousintensity physical activity for ≥ 10 min continuously daily frequency of stair climbing was assessed using one question at home during the last 4 weeks about how many times a day do you climb a flight of stairs these data were only collected from individuals who indicated that they were able to walk response options included none 15 times a day 610 times a day 1115 times a day 1620 times a day and more than 20 times a day environmental exposures exposure to airborne pollutants was estimated using a land use regression model developed as part of the european study of cohorts for air pollution effects project 2425 we included annual average concentration of particulate matter with an aerodynamic diameter of 25 μm and 10 μm as well as nitrogen dioxide modelled at participants residential addresses for the year 2010 residential road traffic noise was modelled for the year 2009 using the common noise assessment methods algorithm 2627 we used l den which is an annual average 24h sound pressure level in decibels with a 10decibel penalty added between 11 pm and 7 am this penalty has previously been added in epidemiological analyses to account for annoyance sleep disruption at night 28 the percentage of the home location classed as greenspace as a proportion of all land use types was modelled using 2005 data from the generalized land use database for england 29 for the 2001 census output areas in england each residential address was allocated a circular distance buffer of 1000 m representing widerarea greenspace health status data on 81 cancer and 443 noncancer illnesses were ascertained through touchscreen selfreport questionnaire and confirmed during a verbal interview by a trained nurse in order to provide a single health indicator based on a previously defined algorithm we used a classification developed by the reinsurance group of america in which an experienced underwriter classified each illness according to whether it was likely acceptable for standard life insurance 30 participants were thus classified as healthy or unhealthy based on their reported cancer and noncancer illnesses in developing this algorithm the main determinant of whether to classify specific illnesses as healthy or unhealthy was their corresponding allcause mortality risk this classification does not account for the number of illnesses or temporality of diseases in a separate analysis we have shown that uk biobank participants classified as unhealthy had a twofold increase in their risk of allcause mortality compared to participants who were classified as healthy 31 two secondary health outcomes were assessed firstly whether patients had a longstanding illness disability or infirmity was assessed using the question do you have any longstanding illness disability or infirmity to which individuals could respond yes or no secondly participants perceived health was assessed using the question in general how would you rate your overall health response options included poor fair good and excellent these health outcomes will be termed longstanding illness and selfrated health exclusion criteria women who were pregnant at the time of assessment were excluded from the analysis based on the assumption that lifestyle patterns change during pregnancy 32 participants for whom their genetic sex inferred from the relative intensity of biological markers on the y and x chromosomes and selfreported sex did not match were also excluded as this may reflect poor data quality statistical analyses participants with baseline data on all explanatory variables and health indicators were selected for crosssectional analyses participants with missing data or who responded do not know or prefer not to answer were excluded logistic regression analyses were used to estimate associations between sociodemographic characteristics psychosocial factors lifestyle factors and environmental exposures with health status and longstanding illness ordinal logistic regression analyses were used to estimate associations between these factors and selfrated health across these outcomes poor health was the reference group in determining the reference groups for categorical explanatory variables we focused on interpretability of the results for middleaged and older uk residents for each explanatory variable we fitted incrementally adjusted models using the baseline uk biobank data model 1 included only individual explanatory variables model 2 included individual explanatory variables plus age and sex model 3 included all explanatory variables within a given domain plus age and sex model 4 was a full multivariable model that included all explanatory variables all models were fitted in the analytical sample without missing data to ensure that any differences between models were not due to inclusion of different participants we calculated odds ratios and bonferroniadjusted confidence intervals adjusted p values were calculated to account for multiple testing within each model two methods were used bonferroni and benjamini hochberg 33 all twotailed with α 05 and false discovery rate of 5 respectively we report bonferroniadjusted p values for most results for the interaction analyses we report intext the most conservative correction at which statistical significance was reached and present both sets of adjusted p values in additional file 1 multicollinearity was assessed using generalised variance inflation factors 34 to compare the magnitudes of association between the explanatory variables and health indicators we calculated standardised regression coefficients by rescaling all variables included in model 4 to have a mean of zero and by dividing the coefficients of numeric variables with more than two values by twice their standard deviation 35 to assess whether any associations between explanatory variables and health indicators were modified by sex or age we stratified analyses by sex and by age at baseline assessment and assessed potential age and sex interactions by adding crossproduct terms to model 4 the choice of age strata was based on the current uk retirement age to assess whether the explanatory variables assessed at baseline predicted selfrated health at followup we applied the same modelling strategy to the subsets of participants with repeat assessment data we additionally adjusted for the number of days between the baseline and followup assessments in these analyses this additional adjustment was included to account for the possibility that individuals who had their first or second revisit closer to the baseline assessment would be less likely to have had changes in their selfrated health as variable selection and classification might impact results we conducted multiple additional analyses to examine related variables categorised continuous variables according to health guidelines or previously determined cutoffs and tested the robustness of our findings to additional exclusion criteria we repeated the main analysis with the townsend deprivation index instead of the index of multiple deprivation for england as measure of neighbourhood deprivation examining each individual component of the index of multiple deprivation for england separately with sleep duration as categorical variable 36 with bmi as categorical variable with body fat percentage instead of bmi as measure of body composition excluding individuals who reported that they stopped drinking alcohol because of illness or ill health or doctors advice subdividing individuals who reported that they never drink alcohol into current and lifetime abstainers with current tobacco smoking only with metabolic equivalent task minutes per week for walking moderate physical activity and vigorous physical activity 37 instead of the number of days per week spent engaging in these activities for ≥ 10 min reducing the greenspace percentage circular distance buffer from 1000 to 300 m to examine nearby greenspace with air pollution and noise exposure estimates dichotomised according to who recommendation thresholds 3839 statistical analyses were conducted using r results study population of 502521 uk biobank participants 532 had missing health data and 3351 had missing data on explanatory variables or did not meet our inclusion criteria hence our analytical sample included n 307378 adults missing data for each explanatory variable are described in additional file 1 fig s1 descriptive statistics are presented in additional file 1 tables s2s5 there were few differences between the full and analytical sample with the analytical sample slightly healthier and more educated of the participants in the analytical sample 818 reported at least one cancer and 7330 at least one noncancer illness approximately two thirds of participants were classified as healthy while 3096 were unhealthy a similar percentage of participants reported having a longstanding illness finally 360 rated their health as poor while 1925 5944 and 1771 rated their health as fair good and excellent respectively regression analyses we found weak correlations between most continuous explanatory variables and moderate to strong correlations between the environmental exposures generalised variance inflation factor values for model 4 were between 102 and 262 for 19 21 explanatory variables the vifs for no 2 and pm 25 were 608 and 427 respectively excluding no 2 from the model reduced the highest vif to 242 fitting model 4 without no 2 or with each air pollutant separately had little impact on their associations with health status as such we report the results for model 4 that included all explanatory variables unless indicated otherwise results presented below correspond to multivariableadjusted odds ratios and bonferroniadjusted confidence intervals from model 4 a simplified overview of our findings is presented in additional file 1 tables s6s9 increased age was associated with lower odds of favourable health status men had lower odds of being healthy individuals with a high income had higher odds of being healthy while those with lower levels of income had lower odds of being healthy increased neighbourhood deprivation was associated with lower odds of being healthy compared to whites individuals of black chinese mixedrace and other ethnic background had higher odds of being healthy in model 1 but only chinese ethnicity was associated with higher odds of being healthy across all models compared to individuals without educational or professional qualification participants with any qualification had higher odds of being healthy in model 1 after adjustment for age and sex and except for a levels or equivalent education level in model 3 that included all sociodemographic characteristics however there was only limited evidence of associations between participants qualifications and health in model 4 loneliness was associated with lower odds of favourable health status socially isolated individuals also had lower odds of being healthy but the strength of association was weaker than for loneliness in model 4 longer sleep duration was associated with lower odds of favourable health status walking frequently and engaging in frequent vigorous physical activity was associated with higher odds of being healthy across most analyses although moderate physical activity was associated with higher odds of being healthy in models 1 and 2 we did not find evidence of an association in models 3 and 4 note bonferroniadjusted confidence intervals or odds ratio ci confidence interval gcses general certificate of secondary education cse certificate of secondary education nvq national vocational qualification hnd higher national diploma hnc higher national certificate na not applicable 1 annual household income groups very low low middle high and very high 2 in our analyses of environmental exposures higher pm 25 concentration was associated with lower odds of favourable health status pm 10 was also associated with lower odds of being healthy in models 1 and 2 but there was no evidence of an association between pm 10 and health status in models 3 and 4 no 2 was associated with lower odds of being healthy in models 1 and 2 however in models 3 and 4 there was no evidence that no 2 was ambient sound level was associated with lower odds of being healthy in models 1 and 2 but there was no evidence of an association with health status in models 3 and 4 finally we did not find consistent evidence of an association between percentage greenspace within a 1000 m circular distance buffer and health status full results for longstanding illness and selfrated health are presented in additional file 1 tables s10s21 model 4 results across health indicators are presented in figs 1 2 and3 findings regarding income sex and neighbourhood deprivation were mostly consistent across health indicators although with some variation in the magnitude of associations compared to whites participants of chinese ethnicity had lower odds of favourable selfrated health confidence interval plot confidence intervals for model 4 gcses general certificate of secondary education indicates reference group for categorical explanatory variables for categorical explanatory variables the odds ratios for selfrated health indicate the changes in odds of reporting better selfrated health associated with the explanatory variable group relative to the reference group odds ratios for continuous explanatory variables for selfrated health indicate proportional odds ratios for a 1unit increase in the explanatory variable on level of selfrated health annual household income groups very low low middle high and very high gcses also includes o levels and certificate of secondary education a levels also includes national vocational qualification higher national diploma higher national certificate and other professional qualifications fig 2 lifestyle factors associated with health indicators confidence interval plot confidence intervals for model 4 bmi body mass index indicates reference group for categorical explanatory variables for categorical explanatory variables the odds ratios for selfrated health indicate the changes in odds of reporting better selfrated health associated with the explanatory variable group relative to the reference group odds ratios for continuous explanatory variables for selfrated health indicate proportional odds ratios for a 1unit increase in the explanatory variable on level of selfrated health fig 3 environmental exposures associated with health indicators confidence interval plot confidence intervals for model 4 pm particulate matter no 2 nitrogen dioxide l den dayeveningnight noise level odds ratios for selfrated health indicate proportional odds ratios for a 1unit increase in the explanatory variable on level of selfrated health but had higher odds of being classified healthy and being free from longstanding illness individuals of nonwhite ethnic backgrounds tended to rate their health less favourable but there was some evidence that they had higher odds of being free from longstanding illness especially in the full multivariable model individuals with any qualification had higher odds of rating their health more favourable while results were less consistent for health status and longstanding illness especially in models 3 and 4 finally older individuals tended to rate their health more favourable findings regarding psychosocial factors were consistent across health indicators but the association was strongest for loneliness and selfrated health findings regarding lifestyle factors were consistent across health indicators except that there were some inconsistencies in the associations between dailyalmost daily alcohol intake and health more frequent moderate physical activity was associated with better selfrated health also in model 4 longer sleep duration was associated with better selfrated health but there was little evidence of an association with having a longstanding illness higher levels of pm 25 were also associated with lower odds of being free from longstanding illness while we found similar associations with selfrated health in models 13 pm 25 was associated with better selfrated health in model 4 there was no evidence of an association between pm 10 and any health indicator in models 3 and 4 although pm 10 was associated with poor health across outcomes in models 1 and 2 higher no 2 concentration was associated with less favourable selfrated health while there was no evidence of an association with health status and having a longstanding illness after adjusting for covariates in models 3 and 4 higher l den was associated with poor health in models 1 and 2 but we found no evidence of an association in model 4 for longstanding illness and selfrated health there was some evidence that higher l den was associated with better health in model 3 percentage greenspace was associated with better selfrated health and higher odds of being free from longstanding illness in models 1 and 2 results from model 3 suggested that greenspace was associated with less favourable health across all health indicators but we found no evidence of any associations in model 4 after bonferroni correction magnitude of associations standardised regression coefficients for health status are presented in fig 4 most notably the magnitude of association between bmi or being on a very low income and health status were comparable to that of current smoking there was also a substantial difference in the magnitude of association with health status between the very low and low income groups the magnitude of association between loneliness and health status was substantially larger than that of social isolation finally associations between the environmental exposures and health status were relatively small compared to those observed for the sociodemographic psychosocial and lifestyle factors associations with longstanding illness and selfrated health compared to health status were stronger for household income sex neighbourhood deprivation loneliness social isolation walking frequency vigorous physical activity bmi and stair climbing frequency stratified and interaction analyses descriptive statistics of the analytical sample stratified by sex and age group are presented in additional file 1 tables s25 ands26 findings presented below correspond to results for which the stratified and interaction analyses provided consistent conclusions full results and effect sizes are presented in additional file 1 tables s27s50 fig s7s24 the odds of being healthy were lower for men than for women in the lowest income group 0001 the association between increased age and lower odds of being healthy was stronger in men 0001 asian women had higher odds of being healthy 0007 the association between neighbourhood deprivation and lower odds of being healthy was stronger in men 0001 men who were lonely had lower odds of being healthy 0008 and social isolation was associated with lower odds of being healthy only in men 0006 longer sleep duration was associated with lower odds of being healthy only in men 0001 reporting frequent alcohol intake was associated with higher odds of being healthy only in men 0023 for 34 timesweek and p bh 0039 for dailyalmost daily the association between higher bmi and lower odds of being healthy was stronger in men 0001 the association between former smoking and health status was stronger in men 0001 while the association between current smoking and health status was stronger in women 0005 pm 25 was associated with lower odds of being healthy only in men 0011 finally we found that no 2 was associated with higher odds of favourable health status only in women 0024 the association between being on a very low income and lower odds of being healthy was stronger in participants below the age of 65 than in participants aged 65 and above 0001 reporting an income of £52000£100000 was associated with higher odds of being healthy only in participants younger than 65 0016 men aged 65 and above had lower odds of being healthy 0001 loneliness and social isolation were associated with lower odds of being healthy only in individuals younger than 65 0024 and p bonf 0011 respectively the association between walking frequency and higher odds of being healthy was stronger in individuals aged 65 and above 0001 climbing stairs 15 timesday was associated with favourable health status only in individuals younger than 65 0001 there was some evidence that the association between never drinking alcohol and poor health status was stronger in individuals younger than 65 0002 the association between higher bmi and lower odds of being healthy was stronger in individuals aged 65 and above 0001 finally the association between current smoking and poor health status was stronger in individuals younger than 65 0038 although there were some differences stratified and interaction analyses of longstanding illness and selfrated health indicated a large degree of consistency with the results observed for health status longitudinal analyses we repeated our analyses of selfrated health in participants with followup data collected between 2012 and 2013 and between 2014 and 2019 descriptive statistics and full results are presented in additional file 1 tables s51s59 the findings were fully consistent with crosssectional analyses for very low high and very high levels of income sex loneliness sleep duration walking frequency vigorous physical activity infrequent alcohol intake bmi and smoking status although many results were consistent across timepoints we found some differences between crosssectional and longitudinal analyses for low income age neighbourhood deprivation ethnicity highest qualification social isolation moderate physical activity stair climbing frequency regular alcohol intake and the environmental exposures additional analyses additional descriptive statistics are presented in additional file 1 table s60 repeating the main analysis with the townsend deprivation index as measure of neighbourhood deprivation that does not include a health dimension led to similar conclusions as for the index of multiple deprivation for england we also found that higher scores on each individual component of the index of multiple deprivation for england except for the housing dimension were associated with lower odds of favourable health status for sleep duration and bmi we found evidence of nonlinearity in the association with health status hence we also examined these explanatory variables as categorical variables compared to individuals with optimal sleep duration those who slept 7 or ≥ 9 hday had lower odds of being healthy we also found that low and high bmi was associated with lower odds of being healthy compared to a bmi of 185249 kgm 2 there was no evidence of substantial departure from a linear association with health status for all other continuous variables repeating the main analysis with body fat percentage as measure of body composition led to similar conclusions as for bmi higher fat percentage was associated with lower odds of being healthy excluding individuals who reported that they had stopped drinking alcohol due to illness or their doctors advice attenuated the association between never drinking alcohol and health status when subdividing individuals who reported that they never drink alcohol into current and lifetime abstainers the association with health status was stronger in current abstainers restricting analyses to current smoking we found that regular smoking and smoking only occasionally was associated with lower odds of being healthy although the magnitude of association was stronger for regular smoking examining met minutes instead of the number of days per week spent walking engaging in moderate or vigorous physical activity led to similar results when we examined air pollution and noise exposure estimates dichotomised according to who recommendation thresholds we found no evidence that being exposed to ≤ 10 μgm 3 pm 25 on average annually was associated with higher odds of being healthy after bonferroni correction there was also no evidence of an association with health status for exposures to ≤ 20 μgm 3 pm 10 ≤ 40 μgm 3 no 2 or ≤ 53 decibels l den in model 4 we also did not find evidence of a threshold in the association between pm 10 or no 2 and health status when including quintiles of these exposures in model 4 restricting analyses to participants assessed after 2008 or 2009 or to those who had lived at their current address for at least 10 years did not lead to different conclusions regarding the associations between environmental exposures and health status there was no evidence that percentage greenspace within a 300m circular distance buffer was associated with health status after bonferroni correction truncating continuous explanatory variables at the 1st and 99th percentile did not materially change our results discussion increased age was strongly associated with unfavourable health status and having a longstanding illness however older participants generally rated their health positively which is consistent with several smaller studies 4041 though not all 4243 ageing might be the single most important factor underlying disease 44 with an almost universally accepted expectation of declining health as people get older as attainable health states shift with age 45 older participants might evaluate their health more favourable despite higher rates of illness and disability although women on average report more illnesses disabilities and limitations in daily life 46 47 48 one of the most robust findings in human biology is that they live longer than men 49 our findings are consistent with results from the newcastle 85 cohort study in which women rated their health more favourably than men 46 however other studies reported that women rated their health less favourably than men 50 51 52 or did not find evidence of sex differences in selfrated health 5354 sex differences in health status could result from differences in the frequency of specific illnesses sexspecific reporting patterns or biological and social factors 52 discrepancies in findings between studies might reflect differences in age group or sociocultural factors high income and low levels of neighbourhood deprivation were associated with better health which is broadly consistent with previous studies 55 56 57 notably we found only a small difference in the strength of association with health status and having a longstanding illness between the highincome groups the difference between the lowincome groups however was substantial supporting previous findings which suggested a nonlinear association between family income and mortality 58 for selfrated health we also found evidence of substantial differences between the highincome groups a possible explanation for the observation that there was less evidence of associations between household income and health in individuals aged 65 and over than in the younger age group is that more individuals in this age group received a pension income future studies could examine associations between health and related socioeconomic variables such as family income or household income per capita our study provides limited evidence that education was independently associated with favourable health status after accounting for other factors although higher levels of qualification remained associated with better selfrated health consistent with previous research 42 a recent uk biobank analysis showed that remaining longer in school causally reduced participants risk of diabetes and mortality 59 a potential explanation for why we did not find a consistent pattern in the full model is that most differences in health status result from educated individuals engaging in healthier lifestyle behaviours 60 that we had accounted for or they could be due to socioeconomic or genomic factors social isolation and loneliness were associated with poor health the strength of association was greater for loneliness particularly in men and in individuals below the age of 65 social isolation and loneliness were not always correlated 6162 and represent different aspects of social relations in a metaanalysis of 70 studies social isolation loneliness and living alone were associated with a 2632 increased mortality risk 16 there was no evidence of differences in mortality between these measures although the strength of association was greater in individuals below the age of 65 consistent with our findings a recent uk biobank analysis found that socially isolated and lonely individuals had an increased risk of death but only social isolation predicted allcause mortality in a joint model 22 the discrepancy with our finding might reflect differences in outcome measures long sleep duration high bmi and past and current smoking were associated with poor health sleeping less than 7 hday was also associated with poor health consistent with a metaanalysis that provided evidence of a ushaped association between sleep duration and allcause mortality 36 a bmi outside the optimal range of 185249 kgm 2 was also associated with poor health consistent with previous research that examined allcause mortality 60 physical activity is a key lifestyle factor recommended for primary and secondary prevention of chronic health conditions 63 and is associated with lower mortality risk 64 in this study walking frequency especially in individuals aged 65 and above stair climbing and engaging in vigorous physical activity was associated with good health moderate physical activity was associated with better selfrated health especially in men a study in middleaged british men found evidence of an association between vigorous but not moderate physical activity and reduced mortality 65 reviews of the literature report mixed findings on the relative contributions of moderate and vigorous physical activity 6667 with some evidence suggesting stronger associations for vigorous activity 68 a more frequent drinking pattern was associated with better health in this study alcohol drinking often occurs in a social context and might therefore constitute a proxy for social wellness supported by the finding that nondrinkers tend to be characterised by poor psychosocial health and low socioeconomic status 69 moderate drinkers also perform more sports than lifelong abstainers 70 drinking less frequent than 12 times week was associated with poor health and could not be fully accounted for by excluding individuals who had discontinued alcohol intake for health reasons or because of their doctors advice however the association with health status was stronger for current abstainers suggesting that some individuals are nondrinkers in later life due to illness 71 current abstainers who quit drinking for health reasons could exaggerate poor health outcomes associated with not drinking alcohol 72 those who never drink might also differ from current drinkers in other characteristics 69 road traffic noise and ambient air pollution are environmental risk factors for health while we found some evidence that higher levels of all airborne pollutants were associated with poor health only pm 25 was associated with unfavourable health status and having a longstanding illness after adjustment for other factors higher levels of no 2 were associated with less favourable selfrated health a joint analysis of uk biobank hunt and epicoxford data did not find evidence of an association between no 2 and incident cardiovascular disease although both pm 25 and pm 10 were associated with higher incident cardiovascular disease 73 adjustment for physical activity and neighbourhood deprivation in the present study could have contributed to differences in findings between studies few individuals in our study were exposed to levels of pm 10 and no 2 above recommended guidelines which might explain why we did not find strong associations between these pollutants and health the only exception was pm 25 for which 45 of our sample were exposed to levels above the who recommendation threshold of ≤ 10 μgm 3 positive associations between pm 25 and selfrated health might represent spurious associations or statistical artefacts we are not aware of any mechanisms linking higher levels of pollution to good health while higher levels of residential noise were associated with poor health in models 1 and 2 there was no evidence of an association after adjustment for other factors our findings are consistent with a previous analysis that did not find evidence of an independent association between l den and cardiovascular disease ischemic heart disease or cerebrovascular disease 73 we found some evidence that greenspace was associated with better selfrated health consistent with a recent metaanalysis 74 although not after adjustment for other factors several previous studies examining associations between greenspace and health did not adjust for physical activity and most did not include other environmental exposures such as air pollution or noise 74 these differences could partially explain why we did not find consistent associations in this study strengths and limitations the large sample size enabled high precision in the estimation of associations and it allowed us to explore a wide range of explanatory variables sex and agespecific associations interactions and additional analyses with further classification of explanatory variables many of the findings from previous studies that we replicated in our analyses were conducted in smaller populations and with one exposure at a time often providing limited insight into the multifactorial nature of health one of the contributions of this study is that it allows for systematic comparisons of a broad range of factors associated with health we examined three health indicators with slightly different ascertainment while our findings were fairly consistent across these outcomes we also identified differences between objective and subjective health overall health is arguably what matters most to people and exploring factors associated with health indicators that transcend traditional diseaseboundaries could represent an effective strategy to increase longevity and improve healthy life expectancy previous studies have often used composite scores of healthy lifestyles 14 in which individual behaviours were weighted equally even though the strength of their respective associations with health might differ in the present study we estimated associations separately for each lifestyle factor nevertheless our study has limitations crosssectional analyses prevent examination of temporal sequences reverse causality such as poor health and disability leading to an unhealthy lifestyle less favourable socioeconomic outcomes fewer social interactions or living in more deprived and polluted areas needs to be considered except for fixed characteristics such as sex and ethnicity associations reported here cannot be interpreted as causal effects and there are modelspecific limitations that need to be considered when interpreting these results residual confounding needs to be considered when examining associations from model 1 and model 2 while associations from model 4 might be overadjusted and there is the possibility that some variables included in model 4 could lie on the causal pathway of other variables the intermediate model 3 in which we examined only variables from each broad group of explanatory variables plus age and sex partially addresses this concern and provided mostly consistent results although we have focussed on associations that were consistent across models 14 in the main body of the text and highlighted inconsistencies there was a large degree of consistency in direction of association across models and health indicators as noted above the notable exception to this pattern was education for which we did not find consistent associations with favourable health in the full multivariable model this is likely due to other explanatory variables being on the causal pathway from education which is determined fairly early in life to health in middle to old age indeed a potential limitation of using a standard set of covariates across models is that this approach does not fully consider the specific role each covariate may have for a given exposureoutcome pair as many explanatory variables were selfreported we cannot exclude the possibility that social desirability might have influenced responses for example previous research has shown that up to half of participants who claim to never have had an alcoholic drink reported alcohol intake during previous surveys 75 for most participants explanatory variables were measured at a single time point which could increase the potential for measurement error and did not allow us to model changes across the life course however there is evidence that lifestyle is fairly stable in this age group with few people newly adopting a healthy lifestyle in middle age 76 future research should explore predictors of changes in health status over time using longitudinal data for example using linked patient records we did not include a measure of diet quality or quantity in our analyses despite it being a key healthrelated behaviour as detailed information on diet at the baseline assessment was only available for about 13 of participants 77 examining the frequency of specific food consumption available for most of the uk biobank sample was beyond the scope of this study there might be some misclassification in the reporting of medical illnesses however participants were asked to report illnesses that had been diagnosed by a doctor and these were confirmed during the nurseled interview generalisability the overall response rate of the uk biobank was low and compared with nonresponders participants were older more likely to be female and lived in less deprived neighbourhoods participants were also less likely to be obese to smoke to never drink or to drink alcohol dailyalmost daily and they reported fewer health conditions compared with data from a nationally representative survey 78 while the uk biobank states that valid assessment of exposuredisease relationships are nonetheless widely generalizable and do not require participants to be representative of the population at large 79 concordant with the finding that there is little evidence of considerable bias due to nonparticipation in epidemiological research 80 the magnitude of exposuredisease associations may depend on the prevalence of effect modifiers 81 a recent empirical investigation comparing the uk biobank with data from 18 prospective cohort studies with conventional response rates showed that the direction of risk factor associations were similar although with differences in magnitude 82 conclusion our findings shed light on some of the behavioural psychosocial and environmental pathways to health and are thus relevant to public health policies aimed at promoting health in later life public health and medicine could put greater focus on nonmedical factors such as loneliness further encourage healthy lifestyle behaviours and weight management and examine efforts to improve the health outcomes of individuals on a low income our findings support the view that promoting individual responsibility for ones health and policylevel commitments both need to be considered in population health while associations between lifestyle and health might reflect a lifelong commitment to healthy behaviours it is not too late to newly adopt healthy behaviours later in life 76 prevention in addition to drug discovery and disease treatment should be the top priority for health policy access to all the data used in this study and takes responsibility for the integrity of the data and the accuracy of the data analysis additional file 2 health status classification authors contributions cml acquired the studentship funding jm and cml conceived the idea of the study jm acquired the data jm carried out the statistical analysis jm and cml interpreted the findings jm wrote the manuscript cjr and cml critically reviewed the manuscript and jm revised the manuscript for final submission all authors read and approved the final manuscript jm had full consent for publication not applicable competing interests jm receives studentship funding from the biotechnology and biological sciences research council and eli lilly and company limited cml is a member of the scientific advisory board of myriad neuroscience cjr does not declare any potential conflict of interest

background a greater understanding of the factors that are associated with favourable health may help increase longevity and healthy life expectancy we examined sociodemographic psychosocial lifestyle and environmental exposures associated with multiple health indicators methods uk biobank recruited 500000 participants aged 3773 between 2006 and 2010 health indicators examined were 81 cancer and 443 noncancer illnesses used to classify participants health status longstanding illness and selfrated health exposures were sociodemographic age sex ethnicity education income and deprivation psychosocial loneliness and social isolation lifestyle smoking alcohol intake sleep duration bmi physical activity and stair climbing and environmental air pollution noise and residential greenspace factors associations were estimated using logistic and ordinal logistic regression results in total 307378 participants mean age 561 years sd 807 519 female were selected for crosssectional analyses low income being male neighbourhood deprivation loneliness social isolation short or long sleep duration low or high bmi and smoking were associated with poor health walking vigorousintensity physical activity and more frequent alcohol intake were associated with good health there was some evidence that airborne pollutants pm 25 pm 10 and no 2 and noise l den were associated with poor health though findings were not consistent across all models conclusions our findings highlight the multifactorial nature of health the importance of nonmedical factors such as loneliness healthy lifestyle behaviours and weight management and the need to examine efforts to improve the health outcomes of individuals on low incomes

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background the provincial government has issued supporting policies in the regional tourism development plan year 20132033 that details a twentyyear plan for the local area tourism development the provincial governments plan is a response to the presidents instruction specifically to regions that have the potential to improve through tourism as a solution to the scarcity of skilled tourism personnel tourism vocational high schools were established which had the further purpose of confronting the unemployment rate nationally with 65 of the population being secondary school graduates the lack of graduate skills is evident the tourism sector has impacted the local economy directly in the form of job opportunities and business opportunities there are now twelve sea resorts sixty accommodation units forty vessels and so on meanwhile in manokwari the capital city of west papua the development of the tourism sector is marked by the establishment of two standard hotels the swissbelhotel and the aston niu hotel tourism developments in west papua have been marked by two more vocational schools majoring in tourism which raises important issues for further discussion many assumptions can be made regarding the vocational tourism high schools in the region as educational facilities but most of them are negative the assumptions can be classified as coming from two groups of people the first group is the public while the second group is within the schools system and consists of the school members and the people who are in the local area tourism market the first group mostly thinks that tourism vocational high school is an unqualified school while the second group holds two contrasting views about the school some members say that the tourism vocational high school is a stepping stone while other people in the school think that the place is just any port in a storm the first assumption held by public or the community seemingly comes from an inherited outdated mindset that claims smas or general high schools are the best places to reach your dream the community believes that these general high schools are more qualified to educate their children than other types of school they believe that the high number of successful people who graduated from senior high school since 1950s is sufficient evidence for them to take the same step in addition they have not yet realized the potential of economic success in the tourism industry the general belief amongst community members has been that studying science and being a civil servant provide a more secure future therefore many parents encourage their children to enroll in general high schools or vocational schools that major in business and economy all high schools except the tourism vocational high schools have long been preferred by the community no wonder that every year the tourism vocational schools have lower enrolments than the other schools the research questions addressing the research problems are how might west papuan tourism vocational high schools be developed for sustainability and relevance to the tourism sector the following sub questions articulate the detailed issues for examination the first question is what underlies the assumptions of the west papuan community towards the tourism vocational high school in the region secondly what will the future scenario be like third question is how will the future scenario be achieved and the last question is how will the present and future narrative be told literature review a current litany tourism in indonesia recently the growth of the tourism sector in indonesia has contributed around 41 to the gdp 59 of employment and 213 of the oecd trade in services figures a researcher of indonesian tourism from jenderal soedirman university chusmeru said that the indonesian tourism sector in the year 20182019 has experienced a significant and encouraging increase the indonesian tourism sector has made many achievements therefore any policy aiming to supporting the tourism business should be linked to the education system in order to improve the number of qualified tourism personnel b most community perceptions according to h oktadiana and chon most indonesian people think that vocational education is a program requiring less academic performance and featuring lower quality processes than other longestablished subject areas subrahmanyam even reports that many people believe enrolling in a vocational school means closing their future pathways in africa for example vocational schooling does not lead to higher education teachers are lowpaid and underqualified and educational environments are oldfashioned the title of secondchoice is what most youngsters and their parents strenuously shun vocational education does not prioritize the accepted areas of learning such as math natural sciences social sciences but even in vocational schools the most favoured subjects are business management and engineering therefore it is evident that many parents are concerned about the academic credibility and legitimacy of the educational institution that their children enrol in other perceptions that the community have towards the tourism vocational education are revealed in the jiang and tribe study in china the data show that the chinese community behaves negatively towards vocational education because of the tourism industrys well known features such as stressful jobs lack of family life due to the nature of work long working hours fatiguing and unstable jobs low social status disappointing and unjust promotions low income and poor wellbeing unqualified managers poor attitudes and behaviour of managers towards employees incompetent coworkers bad attitudes and behaviour of fellow workers and poor physical working conditions for staff thus even though the tourism industry in china is prosperous the communitys attitude towards the business is generally negative c current systemic government priorities in tourism sector the ministry of tourism this plan aimed to provide accountable and reliable information regarding programs and activities for achieving the national tourism development targets year 20152019 the national longterm plan year 2005 2025 was enacted in in act 17 year 2007 in order to strengthen the economy nationally but also to become globally competitive in a public speech the president of indonesia announced that tourism is to be developed to increase the local peoples welfare and open employment opportunities moreover the wise utilisation of natural resources sustainable management and the preservation of local cultures are major considerations as well both local and national governments determine the success of the tourism development of an area according to hamsinah the establishment of otonomi khusus in the land of papua has empowered not only the local governments but also local communities to manage their regions potential in order to achieve the goals of local development they have greater opportunity to be the master of their own land one of the tourist attractions in west papua that is a good example of the success of local empowerment is raja ampat islands on the coast of sorong the largest city in west papua the development of tourism in raja ampat is now no longer dependent on national funding but is bringing in regional income d vocational education as lifelong learning lifelong learning has been part of the education debate since the 1960s nowadays the world has acknowledged the significance of lll and its increasing importance in dealing with technology bahçelerli suggests that lifelong opportunities can be created through vocational schools as long as they can align their programs with the tourism businesses expectations graduates of these schools should be able to manage effective personal development and have the ability to collaborate as well as practise efficient leadership along with computer and communication technologies capability this aligns with the indonesian ministry of educations national strategic plan for the development of vocational high schools which all levels of policy makers especially in the local areas are expected to actively observe mapping the schools demands constant open dialogues are needed in such a process otherwise the plans remain without realisation e tourism policies through vocational education according to kaushik vocational education is defined as occupational and employmentbased education it can be known as career and technical education or technical vocational education and training since the industry of travel and tourism is extremely diverse in terms of its subsector combinations professions and criteria for talent for the rapid improvement of this industry to be supported by corresponding human resources quantity and quality policies have been developed in india to encourage and inspire many young people to enrol in hospitality and tourism educational and training programs governments contributions to tourism and sector growth are widely accepted policy makers in some developing countries have eventually become interested in increasing access to vocational education in order to raise the number of trained human resources for example tanzania focused on this type of education in the late 1960s followed by south korea thirty years later india is another developing country that has made valuable investments in vocational education in tourism and hospitality and has in tackled the same problems that indonesia faces the indian government has been focusing on a strategic planning that is expected to continuously produce skilled employees for its tourism industry thus its tourism service remains well received and viable the indian government has implemented two types of tourism vocational education formal education and training programs the formal education does not necessarily provide the practical skills that the job brand requires on the other hand the vocational training programs include the provision of a diploma in the tourism and hospitality industry mainly granted by the iti and the universities industrial training centres instead of accepting the students with the most potential these courses are usually filled with school dropouts from grades 812 or the 1218yearolds the curricula of the training programs have many special categories that aim to prepare students practically for the work they will do in the industry in the indonesian context the establishment of hospitality and tourism as an independent field of study began on 31 march 2008 letters from the higher education directorategeneral of the republic of indonesia no 947d t2007 and 948d t2008 addressed to the ministry of culture and tourism expressed support for the establishment of bachelors degree programs for tourism in two institutions run by the ministry even though it can be said that the recognition of tourism education is quite new in the education system in indonesia there have been over two decades of efforts and arguments by its scholars there have been many improvements in the hospitality and tourism study programs which have grown by 12 in 2010 with about twenty five institutions offering vocational andor academic bachelor programs it is clearly seen that indonesia has proven its seriousness in filling the gaps of tourism professionals such as scholars researchers tourism planners and policymakers with the purpose of equipping skilful or technical employees nonetheless there are still many unspecified differences between the vocational and academic education systems f vocational high schools in tourism according to mc gladdery and lubbe educational tourism has the ability to encourage education globally but there is very little empirical research to support this argument their study has shown that not all vocational schools survive in this century therefore they have to enable students to experience various cultures in order to prepare them for the global aspects of the tourism industry mc gladdery and lubbe elaborate that students must be helped to develop personal characteristics of curiosity humanitarianism and openmindedness to new experiences however in reality students academic achievement at school tends to be unsatisfactory currently the indonesian governments has been considering developing educational tourism in high schools since the basic education data of 2016 reported that the tourism business still needs personnel of around 625429 people importantly the curriculum should be adjusted to the latest developments in the tourism business field to produce highly qualified tourism personnel and graduates kolbs theory about experiential learning can be applied in the tourism education learning process and has been highly respected by scholars the theory proposed simply defines the learning process through which knowledge is generated by transformational experience linking to the global requirements of education according to tarrant rubin and stoner in the era of globalisation global awareness means a state of recognition and acknowledgement of others in the world and of the worlds issues in other words tourism as a subject in vocational schools should be linked to a global mentality with a greater sense of social responsibility towards both society as a whole and towards the world in order to increase the graduates individual capabilities as potential competitive tourism agents the national government has provided much support such as the establishment of teaching factories and technoparks where strategic programs to improve the students sense of global competitiveness in line with local business requirements however it is recognised by the indonesian educational government that there is need for qualified teachers in the high schools of tourism in west papua who can effectively direct this type of learning so the fulfillment of tourism qualified teachers in quantity and quality must also be considered to maintain tourism vocational schools in west papua g tourism as a subject in vocational education h worldview tourism has globally served as a vehicle for socioeconomic revolution which has lead to significant debates it is used as an instrument for stimulating low economies and fostering growth through jobs and incomes even though not always stated clearly it is often assumed that by encouraging upward capital accumulation tourism will reduce poverty liu and wall further argue that tourism awareness differs between countries in the world partly because of the many forms tourism can take and partly because of the variety of destinations that attract and meet tourists needs there is therefore no widely accepted agreement on what tourism offers because the implications differ from place to place and are conditional more elaborate commentary about the tourism industry according to liu and wall is that it is commonly introduced in the developing world through a topdown planning strategy since it is fundamentally dependent on the intervention of government instruments and big tourism organizations the results are the empowerment of global capital and the marginalization of local people local communities are generally not involved as investors and decision makers since locally there is a lack of knowledge of tourism and the related skills and because policy makers prioritise economic growth with little regard for equity this accords with neoliberalism values which view the educational sector as a commodity that can bring monetary benefit young people in the twentyfirst century are not only expected to fulfil the needs of international competitiveness so they can survive socialeconomically but also have to be well prepared as wellrounded human beings to cultivate humanity as nussbaum postulates education in the era of global connections should be about developing a curriculum that encourages diversity and teaches students mindfulness respect and willingness to recognise and respect others regardless of their origin social class gender ethnicity or place of birth one of the approaches supporting this view is the promotion of positive mental health in school this strategy has been increasingly acknowledged in the international education over the past decades since it links to wellbeing and decreases inner and externalised problems such as insecurity depression drug abuse aggression and antisocial behaviour marshall and marrett describe lifelong learning as related to the idea of a knowledgebased economy that generates the need for learning to occur throughout a lifetime of a person as we now live in a modern civilization lll education becomes very critical regarding to the need for the ability to anticipate and adapt to change the same precepts of lifelong learning are important to apply in tourism education programs if tourism education is to survive the ideal factors for an effective tourism education program are the relevance to its context and also the careful study of the existing social cultural and economic conditions i lifelong learning tourism education methodology this study applies the causal layered analysis to identify what has been happening during the years of the schools establishment and to predict possible solutions towards the problems of tourism vocational high schools regarding student numbers and curriculum to improve its contribution to the sector in the province of west papua cla as a methodology involves a deliberate attempt to disturb existing power dynamics by questioning our definitions and stimulating construction of alternate future scenarios it consists of four layers namely litany social causessystemic discourse worldview and myth metaphor the litany comprises a description of the issues as seen by the public they are the most visible and obvious perceptions frequently overstated particularly in the reports of the news media the social causessystemic layer involves an exploration of the social causes that have led to the issues listed in the litany including the economic cultural political and historical factors behind the issues the discourseworld view frames the analysis this involves exploring the deeper assumptions behind the issue and the beliefs that have shaped the systems and litany mythmetaphor proposes deeper narratives and discovers the common elements and the subconscious sometimes upsetting or paradoxical elements inayatullah points out that in order to construct alternate futures on the vertical level of future studies with the cla study layers the possible fundamental discourses are given more space to appear while the present situation loosens its hold discussion a new worldview the vocational school has been linked with the idea of lifelong learning which according to bahçelerli is about management of individual enhancement along with practising effective leadership therefore nussbaums argument regarding cultivating humanity suits the vocational educations idea of lll the proposed critical key outcomes for the future of creating a fully active person and making efforts to create a deeply interconnected world can also be seen as part of cultivating humanity which involves the following actions first critical selfexamination and thinking about ones own culture and traditions second seeing oneself as a human being who is bound to all humans with ties of concern and lastly enabling narrative imagination the ability to empathize with others and to put oneself in anothers place meanwhile another scholar who has contributed to social sciences and humanities amartya sen proposes a pioneering view of capability sens definition of capability is a persons ability to perform valuable acts or to attain important conditions of being capability reflects an optional combination of things that a person can do or is capable of doing in other words capabilities are opportunities or freedoms to achieve what an individual reflectively considers valuable his view about capability refers to poverty as a capability failure instead of income shortage in the next section the main systemic is discussed in terms of alternative future that depends on the capability of improvement of each individuals role in any group of people in the system b new systemic innovation or continuous improvement the constant search for better products procedures customer service etc has been well recognised as a successful way to secure competitive advantage and as a more efficient approach to the defence of strategic positions however tidd et al argue that this does not guarantee success at all many organisations claim that they need more innovation but even luck can be a success factor however tidd et al think that real success comes from the ability to repeat the trick in other words to continuously and seriously take control of the sequence of actions the fundamental aspect required in the innovation process according to bessant and caffyn should be increasing creativity in solving problems instead of the variety of discovery furthermore crosswhite and rufatlatre suggest it is better to base innovation on the recognised current obstacles then gradually eliminate them rather than define one new set of actions and strategies after another even though the problem seems to be the smallest and the simplest as long as the solution contributes to the desired changes the process is worth maintaining an innovation project takes advantage of tidd and bessants 4ps model position product process and paradigm which refers to paradigm innovation that is shifts in the mental models driving the organizations operations and repositioning the perception of an established product in a particular user context through paradigm innovation the problems that need to be solved can be structured and articulated which then naturally leads to the solutions furthermore schein argues that what is shared mentally is the crucial part of an organisation and hard to shift since it is steady and lies at the deeper level so the paradigm model will have a greater chance to succeed in other words to get a long lasting result the plan will be directed towards reculturing fullan suggests that the ideal action of change in an organisation is changing the way we do things around here instead of the organisations structure an example of this model is how henry ford radically shifted the image of transportation by altering the concept from rare special models designed for wealthy people to affordable products for everyone however managing the paradigm innovation will take time since it deals with the old culture that has been embedded for years within the organisation and more significantly is a new undertaking for the organisation thus an incremental plan which consists of several actions in transforming the old idea in stages is considered to be extremely important as well c relational leadership through multi sector cooperation leadership is considered as the main focus on the innovation since it is believed that it can solve personal social and organisational problems in the future there will be no more slogans managers are people who do things right and leaders are people who the right things even though it has long been well understood that in this globalisation era it is crucial to improve individual capability starting from the school leadership best experienced when the knowledge is formed and shared socially thus relational leadership is going to be applied in the future since it has been recognized worldwide now that it is the ideal model of leadership in the rising knowledge economies and organisational needs of the twenty first century a mental shift will be required from putting the leader as the centre to trusting in the various influential thought processes of the members of the organisation this approach is created through social developments taking place in and through interactions between people senge defines the process as the learning organisation which is a state of constantly learning together and getting learningful at all stages within the organisation interestingly one part of the process of a learning organisation is personal mastery which involves the lifelong learning of the individual the learning organisation may take place during dialogue including thinking together as the team seeks knowledge that cannot be acquired individually for instance the process of listening to each other identifies the competencies and shortcomings of other participants notices the beneficial knowledge and skills and avoids unfamiliar things another important aspect that needs to be included in the new systemic leadership model is that of coherence making which is the indepth shared understanding in terms of the nature of the work just as explained previously about the others aspects this factor is also improved through communication within the team during the daily work recognizing and adopting what works and always creating meaningful moments these factors are incorporated in the appreciative inquiry approach appreciative inquiry is a strategy that involves a paradigm change that transforms wholly the approach prioritises the highly valueadded areas contributed by the appreciative method ai encourages positivity in professional practise by asking questions about the best times and moments of a particular issue that may redirect the thoughts about challenges and shortages and contribute to the best potential cooperrider argues that problem solving mostly had people searching backwards over the pasts reasons it rarely results in new visions since we are busy filling in the gaps moreover cooperrider points out that problem solving leads to selfdefensiveness however there is no thorough examination of the importance of keeping leadership sustainable through crossdisciplinary collaborative approaches the tourism vocational high schools should have a clear framework in the new systemic layer to integrate them with the many sectors involved in the development of the west papuan tourism high schools which are the local governments tourism businesses and the civil society kurucz et al argue that the complex challenges in firms stem from the concepts integrated in the practice conclusion young children learn through repetition but repetition should be meaningful and enjoyable luckily at younger ages children often ask to repeat songs they love it can be fun for them when the teacher plays with the different aspects of music such as tempo volume and rhythm altering these can also serve as language exercises to help students improve fluency pronunciation intonation and retention students can tap or shake a percussion instrument and keep the beat of the songs keeping the beat can help children hear the rhythm of the language help them produce stress and intonation accurately and improve their fluency using instruments to accompany songs sounds great but not all teachers have instruments available luckily creating percussion instruments is easy almost any object can be used as a percussion instrument when tapped on the floor or a desk teachers may not want to encourage students to use objects such as pens pencils and rulers nor have students do rhythm games at their desks because students may tap rhythms later these songs are short fun and easy to sing and they use actual language young learners can use outside the classroom teachers can find simple gestures for each line that add movement to the routines teachers can also create their songs using familiar catchy tunes like these for other routines some teachers like to have an attentiongetter song or chant that helps manage student behavior others like to use a cleanup song after project work it all depends on what works best for each teachers classroom the use of causal layered analysis in this project has demonstrated how this creative and imaginative method can solve a problem systematically the analysis involves looking more deeply at the present and previous circumstances to predict alternative futures instead of simply giving up in face of difficulties in addition the key concepts identified and supported by the relevant literature underpin the project implications and recommendations

this project examines the west papuan communitys assumptions regarding the vocational high school major in tourism specifically the high school in manokwari that was established i n 2007 unfortunately the expectations of the policy makers in the field of vocational education and tourism are not met by the low number of young people who are interested in the school and finally decide to enroll in the school the causal layered analysis cla used in this study looks at the issues through each of four layers namely the litany systemicsocial causes discourseworldview and mythmetaphor the analysis moves from the current scenario through the layers to the construction of a new alternative scenario it is recognized that the school needs innovation in the paradigm of the relational type of leadership model the recommendations propose four main areas of cooperation through the appreciative inquiry approach 1 within the school 2 with the community 3 with the tourism business sector and 4 with the local department of tourism and the department of education the project fills the gap in the literature which lacks research on tourism vocational high schools in west papua

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introduction epistemic communities are said to be projectoriented communities of experts evaluated on their contribution in terms of knowledge where the main criterion for promotion is knowledge production 3 however 5 for wikipedia 7 for open source have argued that taking responsibility is an additional step from being a regular contributor and social interactions with peers may be an additional requirement for being promoted 6 this work addresses this discussion by looking at the electing process of the administrators in the english wikipedia where exists a quite competitive process of election for the managing position called administrator where social connections and knowledge production skills seem to matter from 20060101 to 20071001 which is our period of study there were 1617 rfa with a 492 rate of success burke and kraut 2 proposed a model to predict rfa results1 mainly based on counting attributes for modelling the candidates activity according to the criteria put forward by the guide to rfas2 their models accuracy reached 756 however they did not measure the respective influence of the edits and of the social interaction on rfa results as their measure of social influence is based on the discussion in the article pages which can be considered as productionrelated activities more than social interaction neither did they separate social networking with administrators from social networking with everyone whereas an administrator may be more influential than an unknown user on an rfa result 4 this work aims at addressing these limitations it provides more accurate model than 2 with more simple variables easier to extract from the raw data it shows that beyond a required minimal number of edits social interactions with people and permission to make digital or hard copies of part or all of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page copyrights for thirdparty components of this work must be honored for all other uses contact the ownerauthor copyright is held by the ownerauthor with peers make the difference between success and failure in the rfa model 21 the variables revision activities we extracted the number of revisionseditions made the number of distinct pages edited and the number of distinct categories edited and the repartition of the revisions in order to take into account both the volume and the variety of the revisions we assumed that the talks on the articles discussion pages were related to the revision activities the number of distinct pages the candidates talked on the total number of talks on the articles discussion pages and the gini coefficient fo their repartition social activities we focused on the conversations on the users pages to assess the impact of nonknowledgeproduction interactions we created three weighted and oriented graphs a general one named usersn adminsn admins bursn bureaucrats for each graph we computed the attributes that described the characteristics of each node candidate they have the same name with as suffix the name of the related graph the degree of the node without taking into account the orientation of edges the number of distinct users to whom the candidate posted a message on their user page the number of distinct users that posted a message on the candidates page the total number of messages posted and received by the candidate then we computed multiple centrality measures on the graphs closeness pagerank and betweenness finally we computed the gini coefficients for both the number of messages posted by the candidates and received by them the models we used the random forest algorithm 1 to predict the election with a learning population since we want to understand the contribution of the social attributes in the rfa result we first create two predictive models one based on the revision attributes and one based on the social attributes then we consider a model using all the attributes and then model 3s most relevant attributes results according to the results presented in table 1 social and revision attributes seem to be complementary for predicting the rfa results the random forest method computes the average decrease of accuracy for each tree in the forest when a given attribute is not used according to this metric the most important attributes are revisions talkpages outdegree usersn table 2 details those attributes for predicting successful and unsuccessful promotions global confusion matrix for each of the main 9 attributes but the pagerank there are significant behavioural differences between the promoted and the nonpromoted candidates the interdecile range of the probability density for the promoted candidates is smaller than the one for nonpromoted candidates this suggests that the promoted candidates behave more similarly than the nonones explaining why the models predict better promotion than nonpromotion the successful candidates are also more active than the unsuccessful ones the estimated probability of being elected according to the number of revisions is less than 50 beyond about 2500 revisions and is about 70 beyond 6000 revisions there is a similar behavior pattern and extreme values with not enough case studies for the following attributes categories talkpages outdegree usersn outdegree adminsn indegree usersn successful promotions unsuccessful discussion our results are consistent with the guide to rfa previous results and the theories on epistemic communities regarding the guide we provide much more precise figures of how many contributions and interactions are needed to have a high probability for being elected we show that there are quite narrow windows in terms of number of contributions and discussions in which the chances of being elected are maximized we dramatically simplified the measures proposed by 2 regarding the edit activities with a better evaluation of the chances to be elected while keeping the number of explanatory variables reasonably low and easy to extract from the raw data as supposed for an epistemic community the contribution in knowledge is the first criterion to be considered as a good candidate and a shortage of contribution is often synonymous to failure but once the candidates have proven their competence and their willingness to do the job knowing and being known by these core members who are the future peers makes the difference there are obvious limitations to our work which will be addressed in future work we studied one project only and with not recent data second if our model is good at forecasting the elections it is not as good for the nonelections dropping the extreme cases may improve the prediction

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introduction motherhood is often a positive and fulfilling experience though for too many it is associated with suffering illhealth and even death for women who fail to access quality basic or comprehensive obstetric care 1 40 of pregnant women will have a delivery complication 15 of these will require comprehensive emergency obstetric care to manage potentially lifethreatening complications to mother obstetric referral is the process of directing or redirecting an obstetric client to an appropriate specialist or agency for definitive treatment 2 this definitive treatment may be in form of basic emergency obstetric care or cemoc provided at different health center levels within the referral system equipment staff infrastructure drugs and supplies are important predictors of the level of preparedness for a health facility to manage obstetric emergencies 3 the inability of a given hc to perform some or all the signal functions of bemoc and cemoc in the management of obstetric complications warrants referral of the client to a better equipped health center 4 referral is necessary because not all the care needed may be available at the lower levels of healthcare 5 the health care system in uganda operates on referral basis national regional district referral hospitals to health center ivs iiis iis and is health center iiis offer bemoc while hc ivs through to national referral hospitals offer both bemoc and cemoc services hc iis offer only antenatal care immunization and outpatient services the hc i is not a physical structure but is constituted by village health team members whose role is identifying women with danger signs and are charged with the function of performing referral 6 an effective functional referral system is critical to ensuring access to appropriate and timely emergency obstetric care services which would contribute to reduction in maternal mortality and morbidity 7 there are disparities in accessing emergency obstetric care between urban and rural populations in uganda rural women often experience delays to make a decision to seek care delay to reach place of care and delay in receiving appropriate and adequate care 8 a critical challenge for referral is the inadequate capacity of the health facilities especially the health center ivs to handle emergencies such as caesarean sections or blood transfusion 49 women need effective clinical care provided by kind and competent health workers who are working within a wellfunctioning health system an effective referral system with communication between facilityand communitybased care providers and between health and transport workers in case of complications is important at the time when maternal emergency services are required 10 in a study assessing effectiveness of maternity health care in tanzania it was not clear why late obstetric referrals were persistent 11 they recommended further qualitative studies employing indepth interviews about noncompliance to maternal referral so that these could reveal more information on experiences and perceptions of the women and their families on the referral systems probably digging deeper to explain the mystery behind these persistent late obstetric referrals 12 barriers to implementing referral procedures in the rural tanzania and south uganda as reported by health care providers include having to implement a rigid protocol difficulties in communicating the indication of referral to clients inability to complete the referral process for their clients no communication prior to referral no feedback from main hospital to lower health facilities medical supplies support supervision and harassment by colleagues 1314 inadequate use of ambulance services poor management of patients during transit lack of professional escort unannounced emergency referrals lack of adequate feedback drugs and blood were cited by patients their attendants and health workers as the main barriers to referral to a referral hospital in ghana 15 data from studies documenting womens experiences of obstetric referral in south western uganda is scanty we explored womens experiences before and after they arrived at mrrh for care our study was informed by the andersen healthcare utilization model which describes how health system organization enabling factors and client characteristics influence womens experience and perception of care as they interface with health care facilities predisposing factors include a womans individual characteristics including her demographic factors that influence what she encounters at referral the need factors refer to the actual obstetric complications like severe obstructed labor that led to the need for her to be referred 16 some situations around a given woman at the time of referral may facilitate her transfer to hospital like having money for transport fare or hinder her ability to transfer timely to the hospital like no ambulance vehicle these barriers to referral could have accounted for delays to decide to seek care delays to reach emergency care health facilities and delays to receive emergency obstetric care and were secondary indications to referral in addition to the actual primary obstetric indications delays lead to late obstetric referral and consequent poor maternal outcomes 17 methods study design qualitative descriptive studies are useful in uncovering the full nature of a littleunderstood phenomenon they allow a researcher to explore a topic with limited coverage within the literature using interviews gives focus to the investigation 18 this was an exploratory qualitative study that described the experiences of women referred with an obstetric emergency to mbarara regional referral hospital study country and setting uganda has one of the highest maternal mortality rates in the world which stands at 336 deaths per 100000 live births this translates into 16 mothers dying per day 19 most of which are from late obstetric referrals the study was conducted at mrrh which offers a variety of specialist health care services including bemoc and cemoc it is the teaching hospital for mbarara university of science technology and several health training institutions it serves a catchment population of about 2 million people from the districts of buhweju bushenyi ibanda isingiro kiruhura lyantonde mbarara ntungamo mitooma rakai rubirizi and sheema mrrh also receives referrals from other regional referral hospitals kabale and fortportal regional referral hospitals district hospitals like itojo and nyakibale and serves clients from the neighboring countries of tanzania rwanda as well as refugees from the democratic republic of congo and burundi 20 its maternity unit registers about 10000 births annually about 20 spontaneous vaginal deliveries 5 caesarian sections including 10 obstetric referrals daily from lower health units allover southwestern uganda the hospital has a cesarean section rate of 40 and an obstetric referral load from the peripheral health facilities of 1200 per year the department of obstetrics and gynecology is manned by 15 obstetricians and 28 midwives and offers a 24 h service daily 21 study population and sampling strategy the study was conducted in may 2022 we used the maternity ward admissions register which has a column to show referred clients and reason for referral we confirmed the identity of the referred clients by reading through their case notes to obtain the primary reasons for referral secondary reasons for referral and the referring health center we checked with the woman to ensure she is one captured in the admissions book we recruited women referred with the following complications ruptured uterus eclampsia and retained second twin with intrapartum hemorrhage transverse lie in advanced labour and severe form of obstructed labour these included institutional and traditional birth attendant village health team member referrals with referral notes or any documented evidence of prereferral medical management tbas and vhts are community members with no formal midwifery trainin charged with the role of referral we selected participants receiving care in the normal postnatal wards and excluded those in intensive care unit and high dependency unit because they were too ill to be interviewed participants were purposively selected indepth interviews were conducted until saturation at 13 participants background information from the participants like age and parity was collected during the interviews and all the eligible participants approached agreed to participate in the study we used purposive maximum variation sampling there was diversity during recruitment of participants in terms of age marital status education level socio economic background and distance to mrrh previous referral experience type of emergency to document varied views opinions and experiences despite the differences in obstetric indication for referral saturation was attained when no new information was being given and experiences being shared were becoming similar saturation is taken to indicate that on the basis of the data that have been collected or analyzed further data collection or analysis are unnecessary 22 since it provides no new ideas data collection tools indepth interviews were chosen because they can be used to explore the views experiences beliefs and motivations of individual participants 23 the interview guide was developed based on the literature reviewed and relevant probes employed to capture client experiences during transfer to mrrh it had about 15 openended questions capturing client background characteristics experiences enablers and barriers to referral it was piloted at another regional referral hospital on three women referred with severe obstetric complications to ensure reliability of the questions in answering the research questions vague questions were removed or rephrased after the pilot study the interviews started with exchange of greetings and a short preamble about the study purpose we then proceeded with an openended question where respondents described what had happened during transfer to hospital data collection written consent was obtained from participants after thorough explanation of the study purpose interviews were conducted after the clients had given birth or their conditions stabilized in a side room to ensure privacy and to facilitate independent responses without external manipulation interviews were conducted by the first author who is a nursemidwife in the local dialect runyakitara and lasted between 40 and 50 min one participant had a stillbirth and another had been referred with eclampsia their conditions were sensitive to proceed with the interviews a spouse and mother to these clients were interviewed as key informants using the same guide to complete their interviews which had been interrupted by an emotional breakdown and nonrecall respectively the interviews were audio recorded transcribed from runyakitara into english by first author data analysis hn read and reread the transcripts took notes and made sense of the texts latent content analysis as suggested by lundman 24 was used first indepth interpretation of the content of text through a systematic classification process of coding was conducted then identifying patterns condensing data without losing its quality was done coding of the data and the analysis were done manually and deductively using a conceptual framework guided by the constructs of the andersen healthcare utilization model the model focuses on three core factors to explain healthcare utilization predisposing enabling and need factors 25 predisposing factors are those associated with the individual receiving care such as the clients demographic characteristics need factors refer to the obstetric complication that led to the need for referral enabling factors are those that relate to facilitators to heeding referral advice such as the womans birth preparedness and complication readiness plan and availability of a functional ambulance system the unit of analysis was an individual interview quotes that best described the various themes and subthemes and expressed what was frequently said by the different participants were chosen after several reviews all the authors agreed to the formulated subthemes and themes ethical considerations the study was cleared by the mbarara university research ethics committee administrative clearance to collect data was sought from the executive director for research mbarara regional referral hospital the purpose of the study was explained to all the participants and written informed consent was signed before participation they gave their information voluntarily and were told that decline to participate did not have any penalties related to access to ongoing or later care figure 1 represents how an interplay of client background factors external environmental factors like poor ambulance system enablers and barriers to referral all have an influence on womans experience of transfer to seek bemoc or cemoc results demographic characteristics of the participants participants were mostly married with low education status and no formal employment the participants were aged 19 to 38 years of age we interviewed 11 women with obstetric complications and 2 attendants as key informants most participants were referred from a 3460 km radius from mrrh the demographic characteristics of our participants are represented in table 1 women´s experiences are the core of the presented data these were affected by significant delays multiple referrals and fear of death financial constraints and exhaustion in labor the findings resulted in 4 themes and 19 subthemes which we have presented in fig 2 below these experiences were mainly negative the themes are enablers barriers poor quality of care and poor health facility organization the theme poor health facility organization was coined from the subthemes hcp absenteeism nonfunctional operating theatres no fuel for ambulance vehicles poor mechanical condition of ambulance vehicles stock outs of emergency drug and no blood bank the poor quality of care theme emerged from the subthemes of poor hcpclient communication unethical hcp behavior and disrespectful treatment the theme enablers to referral developed from the subthemes of knowledge of obstetric danger sign social support and birth preparedness the barriers to referral theme is supported by the subthemes long distance to health facility poor ambulance system and poverty experiences of referral the experiences include significant delays fear of death and multiple referrals significant delays participants reported delays before finally reaching mrrh there were long distances to hcs multiple referral from hc to hcand interruptions in the journeys during breaks to load and offload other passengers where public transport was used transport delays while one had pain was rather exhausting for them there were delays to receive care and participants who had still births felt that their babies could have been saved by a timely operation he didnt have medicine labour pains so he told me to go to another clinic at the second clinic the hcp was heading for a burial so i was taken to a government hc where i spent 2 days they made me to push hard in vain the baby didnt come hcps didnt allow me to sleep they examined me now and again in my private parts and instructed me to continue pushing but i got really tired the chest was paining they gave me a drip for more labour pains i pushed all night until i got exhausted then i told them to give me a note and send me to a bigger hc at the 4th hc the nurse said that since i had already pushed for long they should take me to mbarara hospital directly because they hadnt been with electricity for two days and didnt have the equipment to use in order to operate upon me r11 para 1 referral with obstructed labour the baby was to be borne at 1am because that is the time when the babys head appeared in the morning we remained there and the hws told me that the baby will fig 1 conceptual framework modified from andersens health care utilization model 25 come out but it didnt and later they wrote me a letter and we came here at first when the babys head appeared we were told to look for the babys clothes later the hw came back and said that time to give birth had not come i asked him why then he had sent for baby clothes he said he thought the baby had come but it turned out not i could also touch and feel the babys head down here i almost lost this baby boy because of overstaying at that health facility in the theatre here they found my womb torn but it was repaired i later got lots of pus in my fig 2 themes and subthemes experiences of referral to mrrh with an obstetric emergencycomplication 27 woumb r4 a 19yearold para 1 0 referred to mrrh with obstructed labour from a hc iii they took my wife to theatre at 10pm and she was worked on at 2am they should have worked on her first since we had come in earlier than all those who were worked on first it is unfair now we have lost our baby and my wifes womb fear of death the fear of being the next potential maternal death loomed over the entire maternity wing at a hc iv when a pregnant woman who came in unescorted died shortly after arrival the woman passed on in full view of the other women in labour this caused intense fear among them who imagined they could be the next to die some worried if they could arrive at mrrh alive of course it was too bad to see a colleague die at the health center you are also attending it is scary but since we had labour pains they couldnt stop there was no escape for us on the way i didnt even know we would reach here when she is still alive she would fit almost every 5 minutes no he drove very fast i actually got worried that she would become worse due to the speed i think i was confused by her condition to even tell the time correctly following severe obstructed labor some got severe puerperal sepsis ruptured uteri and underwent hysterectomy others developed vesicovaginal fistula during the prolonged hospitalization this morbidity caused the immense grief the health workers said that my womb was getting rotten so they removed it imagine this was my first pregnancy so i will never have a child this urine that is leaking when will it stop how will i be able to move among people… said amid sobs ri referral with obstructed labor who was referred from a hc over 150km away from mrrh poor quality of care this theme was coined from the subthemes of disrespectful treatment and poor hcpclient communication poor hcpclient communication participants reported poor communication between them and the hcps the clear reasons for referral to mrrh were not communicated to some of them and while at the hcs were not always updated on their progress when they asked they received cold treatment money was solicited from some of them yet they were attending governmentowned health facilities where services should be free of charge they were then sent to mrrh when they failed to pay participants felt that the hcps were noncourteous with unethical behavior and this caused dissatisfaction with care they did not update us on what was happening in theatre so we waited until morning at around 9am they were calling people to receive their babies but i was the last to be called so somehow i thought that since i was the last to be called may be the baby is not well so they called the lady i was with and told her to bring baby clothes and later they called for babys father and so i went they gave me the dead baby we took her for burial disrespectful treatment some women experienced disrespectful care from hcps who were rude and unkind and ended up with adverse pregnancy outcomes as exemplified by one woman a referral from a hc about 200kms away due to obstructed labour she was a primepara gave birth to still birth and later got sepsis peritonitis hysterectomy was done and she later developed foot drop she also got a burst abdomen and was taken to theatre three times she developed vesicovaginal fistula the nurse said that you know you are poor so where are you going to get the money to take you to a bigger hc she talked to us rudely i cried told them that i wont go back to the labour room to push i had pushed for so long the legs got numb i was carried into the vehicle we came here i hate those hws at the 1st government hc where i went they refused to give me a referral letter in time the person am annoyed with is that nurse i actually got damaged by too much pushing i lost my womb we have so far spent about 700000 uganda shillings buying drugs gloves and food i really feel bad about myself r10 some hcps displayed unethical behavior by making women pay for services in government health facilities where user fees were abolished the participants viewed this as unacceptable as can be seen in one of the excerpts below enablers to referral this theme emerged from the subthemes of social support birth preparedness and recognition of danger sign social support participants were able to make it to mrrh owing to the support from family and significant others in form of escort or lending them money compassionate car owners reduced on the cost of car hire transported them for free or on credit as exemplified by some respondents who reported social support from community members the driver allowed to bring us on credit which is why we never used the hc ambulance as we didnt have cash to fuel it we didnt have enough money but the driver was kind and reduced for us on the cost of car hire we have a neighbor an old man he is a family friend and he has a vehicle he transported us to kabuyanda and then then brought us to mbarara we help each other in many ways so we didnt pay him at all birth preparedness birth preparedness aided the referral process for some of the participants women reported having saved money during the antenatal period for use if need arose these savings were later used for car hire this facilitated them to heed referral advice as captured from the excerpt below i saved some money earlier during the pregnancy because i knew this was not a simple pregnancy i didnt want to start asking for financial help at the last minute with no assurance that i would get it so i kept some money on me r9 referral with retained second twin recognition of danger sign some birth companions were knowledgeable about danger signs like difficulty in breathing and when these appeared in their own they hastened to take them for management at bemoc centers my mother says she wondered to herself that if she had left me to spend a night at home what was pressing me in the chest could spread to the abdomen since i was pregnant and then kill me so she rushed to the nearest health center though it also sent us here because there was no medicine to stop my fits poor health facility organization this theme emerged from the subthemes of health care provider absenteeism recognition of danger sign stock out of emergency medicines and inaccessible ambulance vehicles hcp absenteeism most participants moved to at least two hcs before finally coming to mrrh hcp absenteeism at the initial primary hcs visited led to multiple referrals and delayed their access to bemoccemoc the labour ward door was open at the first hc we went to but we did not find a nurse to help me they should always remain at their work places you should tell those at the hc that i went to that it is the main hc but they mistreat patients its a government health unit so they should work on people nonfunctional operating theatres was a problem common to all the referring cemoc centers during our study period other than the obstetric indication for referral a client had an additional reason for transfer the theater power generator had no fuel so the caesarean section instruments could not be sterilized due to power outages absenteeism of doctors midwives and anesthetic officers as seen contributed to the nonfunctionality of the operating theatres as reflected in the excerpt below the health workers said that since i had already pushed they should take me to mbarara hospital directly because they had not had electricity for two days and so didnt have the equipment to use they could not operate on me they said that the only doctor who could operate upon me had not worked that day stock out of emergency medicines participants reported that the medicines to treat them were not available at the primary referral points so they were sent to mrrh to be able to access them i had high blood pressure and they said they wouldnt manage me they didnt have my kind of drugs inaccessible ambulance vehicles the referring health centers had ambulance vehicles but these were inaccessible because they were grounded in poor mechanical condition or referrals lacked money to fuel them participants felt that health centers needed to have standby ambulance vehicles ready to transport them to referral points the one for the health center had a technical problem so we hired a vehicle from town that further wasted our time moving up and down looking for a vehicle to bring us to the big hospital irrational use of government ambulance vehicles was rampant participants who afforded to fuel h ambulance vehicles to transport them urgently to hospital were disappointed when these were used to transport other normal passengers instead they made many stopovers dropping off these passengers before finally bringing them to mbarara regional referral hospital we could have reached mbarara town at 10 am but instead of dropping me first me who was not well at all instead the driver had many stop overs dropping off the other people who were not ill imagine i was delayed for about 3 hours and you know what that means when one has pain remember my husband is the one who fueled that ambulance vehicle our complaints to this driver fell on deaf ears barriers to referral the theme barriers to referral emerged from the subthemes of previous unpleasant referral experience previous birth experience poor ambulance system and long distance to referral center poor ambulance service some of the transport means that they secured were rather risky and uncomfortable bad terrain where motor cycles dont move easily hindered their transit some distance they would walk as the motor cycles were being pushed some journeys would be temporarily halted as they waited by the roadside for their birth companions to look for vehicles for hire before they could resume this caused further delays to reach the nearest cemoc centers we couldnt move any more due to the pain and being 3 people on one motor cycle so we waited by the roadside as my husband went to look for a vehicle to transport us to lyantonde then from lyantonde he had to hire another vehicle to bring us here the vehicle with a pregnant woman uh and they would slow down where there were potholes and humps and now from sembabule to lyantodeuh shaky voice and tears in her eyes previous birth experience there was no perceived need to go to give birth at a hc for participants who have always had prior successful home births these delayed to decide to seek care i have never had strong labour pains i usually see a gush of water then i push my babies safely from home i have had two twin births at home i hoped to have these successfully at home too when the first baby came out i got pains again and because i have already had twins i knew how the whole process goes i usually give birth from my home my garden my babies are always healthy not this business of moving from one hc to the other previous unpleasant referral experience some participants who had heeded prior antenatal referral advice timely only to have poor outcomes with previous pregnancies did not see the essence of reporting to a hc early this time round they stayed home and ended up as late selfreferrals with obstructed labour and impending rupture of uterus with current pregnancy this can be seen from the excerpt below i was told that the baby was not in a good position so when i was told to go to the main hospital when am due i came here in time but there was no electricity at the time i was to be operated upon by the time they operated me they found that the baby had died inside my womb so what did it help to come here early you can still lose a baby even after reporting early to hospital financially draining the cost of referral was overwhelming to most of the participants who had to borrow money or sell personal property to raise transport fare fuel ambulance vehicles or hire vehicles and for upkeep during the long hospitalizations at mrrh having to go back home to solicit for transport fare worsened their delay and increased their risk for developing complications car hire costs were also hiked because car owners had to cater for car wash fees in case the woman soiled their car with blood or liquor amnii getting a special hire taxi was not easy either instead of 10000 shillings they charged us 30000 shillings because we might soil their car they had to charge extra money for car wash after the journey from kabwohe to kashaka it was 30000 and to mbarara 70000they said that it was high blood pressure they didnt have medicine for it they told me to look for it it went for 60000 yet i had only 10000 on me i had to send for a goat to be sold to raise money some drugs we have bought at 60000 80000 or 100000 i thought drugs should be free since its a government hospital long distance to referral center the distance to mbarara regional referral hospital was long participants worried about raising the fare and later on the upkeep at mrrh which is located in an urban area they chose to seek care at nearby health centers yet these were not equipped to handle their conditions this led to the need for multiple referral before coming to mrrh and subsequent second delays well i was told in the antenatal clinic at bubaare that i have to come to mrrh for delivery but when i pushed one of the babies and the second one was not coming i thought to myself let me get 1000 shillings and go to kabwohe hc there are also health care providers like those at mbarara regional referral hospital where i need a lot of money to get there plus the upkeep money needed in that town is too much discussion this study about experiences of obstetric referral yielded 4 interconnected themes and 19 subthemes poor clienthcp communication poor quality of care enablers and barriers to referral most women experienced delay exhaustion and poor quality of care at referral points the referral process was a worrisome journey financially draining and women felt that they had been treated unfairly by health care providers individual socioeconomic constraints and health system delays negatively influenced their experience of obstetric referral process our participants experienced gross difficulty before finally accessing care at the main regional referral hospital in the region mrrh they underwent multiple referrals owing to the inability of the lower hcs to provide bemoc and cemoc who advocates for improvements in timely emergency obstetric care which is care to women with obstetric complications and quality care if reduction in the unacceptably high global maternal and neonatal mortality and morbidity are to be reduced in fact the sustainable development goals agenda aims to reduce the average global mmr to less than 70 maternal deaths per 100000 live births by 2030 102829 however ugandas maternal and newborn mortality remains high at 336 maternal deaths per 100000 live births and 27 newborn deaths per 1000 live births respectively and corresponds to three delays delayed decision to seek care delayed transportation and appropriate healthcare at hc in uganda 15 women die every day from pregnancy and childbirthrelated causes 94 babies are stillborn and 81 newborn babies die this translates into 695701 deaths each year due to complications during pregnancy and childbirth 3031 addressing the 3 major delays associated with maternal and newborn deaths requires identifying barriers at each step of delivering care strengthening the health system to increase access to emergency obstetrics 3032 our study findings indicate that uganda is in dire need of efforts to expedite the achievement of the sdg 2030 maternal health goals such efforts to improve obstetric referral include improvements in hospital supplies and trainings staff to consolidate teamwork and update emergency care skills trainings in customer care emergency obstetric care drills have been found to be vital for performance improvements among obstetric health care providers 153334 maintenance of equipment charitable donations for equipment drugs supplies for blood donation and transfusions have been shown to greatly enhance health care providers efforts to provide emergency obstetric care 15 35 36 37 38 some secondary reasons for referral in our study included lack of health facility supplies systems to sustain such interventions for south western uganda could improve maternal health services health care provider absenteeism caused the third delay at the primary cemoc health facilities the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in uganda is the failure of doctors to be present at work during contracted hours 3940 women in our study failed to access timely cemoc because maternity wards were closed or the doctor and anesthetist to carry out surgery were absent we did not explore extensively the reasons for hcp absenteeism in the current study however some studies suggest that staff attendance to duty could be boosted by providing housing facilities for them within the health center premises so that they are always in the vicinity to provide the desired emergency obstetric services when called upon 41 the ordeal of finally reaching a hc and still end up with poor outcomes is disheartening and will discourage women from seeking skilled birth attendance antenatal care appears to facilitate utilization of emergency obstetric care especially for women with sociodemographic disadvantages it is believed that women could take up referral advice if they attended antenatal care where they can understand why they are being referred 42 on the contrary antenatal referral advice of atrisk women was not heeded by some of our participants who preferred to give birth from home owing to previous unpleasant referral experiences poor hcp attitudes and third delays have potential to keep away from hcs because of no perceived benefit from attendance following late referral women in our study developed complications like puerperal sepsis and vesico vaginal fistula many women get sequelae after a near miss event for every maternal death about 6 women suffer severe morbidities some of which are lifelong the odds of dying or getting a maternal morbidity are higher among those referred late from other hcs 43 although no deaths were reported during our study period most participants suffered major morbidity like secondary infertility following hysterectomy in primiparous women our findings therefore further confirm the alarming morbidity trends in uganda that for every woman or girl who dies from a childbirth complication an estimated 20 or 30 suffer injuries infections or lifelong disabilities including obstetric fistula 29 most participants in this study reported rude cold communication and uunethical behavior from hcps who solicited money from them in a government health facility where userfees were abolished negative medical communication constitutes a major complaint about obstetric care services positive attitudes of health workers and provision of adequate medical information may promote a more positive hospital experience of women in need of obstetric care and enhance future attendance 4445 poor staff attitudes notwithstanding our findings also point to delayed adequate decision making in clinical care where women in obstructed labor pushed for long at primary care points and were retained even after they requested for transfer preservice curricula for hcps in benin malawi tanzania and uganda reveal gaps in womencentered care inclusion of women in decision making and fundamental human rights of individuals 46 which ultimately do not conform to those recommended by the international confederation of midwives competence framework the skill knowledge and behavior gaps for midwifery hcps in uganda need to be addressed 46 in kenya inhospitable formal service providers hindered slum dwellers to seek emergency obstetric care services 47 in our study services were also sometimes not userfriendly owing to poor communication from the health care providers stakeholders suggest that there should be short competencybased inservice trainings in emergency obstetric care to improve knowledgeskills for better clinical practice and subsequent quality of care 48 perhaps trainings in proper execution of obstetric referral customer respectful maternity care are desired now for our setting delay to reach care seems to be the weakest link for all programs addressing the maternal morbidity and mortality question 49 warren also found that distance cost to health facility diversion to inappropriate health facilities are hindering factors to urgent access to receiving obstetric care 750 health facilities have no capacity to adequately respond to and manage women with obstetric complications 51 studies in ethiopia and northern karnataka region of india investigating readiness of hc to manage eclampsia found poor availability of dipsticks for proteinuria tests caesarean sections reported across almost all the public health facilities magnesium sulphate the drug of choice for controlling convulsions was more available in private forprofit health facilities compared with public facilities 5253 participants in our study were also referred mostly from public health facilities due to stockouts of magnesium sulphate this can be devastating in the event that a health worker desires to urgently bring a convulsion to a halt transport delays like no ambulance vehicles ambulance vehicles with mechanical problems no fuel for ambulances coupled with long distance to the main referral hc were rampant in our study such inadequacies also inflate the treatment costs transportation of referred pregnant women to appropriate hcs and en route stabilizing care plays a pivotal role in preventing maternal deaths in lowincome and middleincome countries 54 maternal deaths stillbirths and neonatal deaths were common outcomes in india among women who requested to use the free ambulance services but failed strategies are required to reduce nonuse of ambulance for women with obstetric emergencies 54 women who delayed accessing emergency obstetric care health facilities owing to transport delays in our study also had stillbirths and early neonatal deaths though luckily no maternal death occurred during our study period other than delaying at lower health units delay also occurred at the traditional birth attendants place this echoes kaye and colleagues findings in the study about lived experiences of having sustained a ruptured uterus where it was reported that many women experienced delays at home at the tbas or at the lower health clinics from where they were later referred or from where they referred themselves arriving too late to mulago national referral hospital 55 in a qualitative study done in three states of australia of new south wales victoria and western australia exploring experiences of having survived a severe postpartum haemorrhage and an emergency hysterectomy women described their experience as being between life and death 56 women in the current study were deeply worried death seemed imminent as they observed a colleague die after an eclamptic fit some felt so ill during transfer to mrrh and were not certain they could make it overall challenges to obstetric referral are due to both the client and external factors external environment factors according to the andersens health care utilization model can be equated to the barriers and health care system inadequacies that caused delays in referral the predisposing factors relate to the client background characteristics like poor social economic status while the need factors were the actual direct indications for referral our findings are similar to those of studies from pakistan bangladesh and subsaharan africa in pakistan diverse factors limit womens access to emergency obstetric care services emoc services were unavailable in most health facilities due to staff absenteeism geographic remoteness delayed access and ambulance shortages all of which jeopardize the transfer of seriously ill clients to higher level care facilities 57 women in the current study experienced similar barriers as they sought emoc in bangladesh women needing emergency obstetric care services needed emergency referral and either need to walk to a transport point or be carried in makeshift stretchers resulting in much physical and mental distress 58 women in the current study utilized motor cycle transport sometimes with multiple passengers on a motor cycle which was rather uncomfortable one required immense resilience to use such means of transport on rough roads through hilly terrains in mozambique and tanzania challenges to accessing emergency obstetric care also point to a weak referral process due to its limited functionality 59 nonfunctional referral systems linked to high maternal mortality ratios are common mainly with lmic countries of the world countries in subsaharan africa and some from asia data on obstetric referral in high income countries is scanty this could be that their referral systems are efficient however experiences from nearmiss events in both high income and countries are similar the shortterm and longterm emotional and physical devastation involved is the same regardless of socioeconomic status partners of survivors of severe lifethreatening pregnancy complications in the uk experienced powerlessness and exclusion witnessing the emergency was shocking and distressing the longterm emotional effects for some were profound some experienced depression flashbacks and posttraumatic stress disorder months and years after the emergency these in turn affected the whole family they coped with support from family or staff and clear honest communication from medical staff 60 on the contrary staff communication to our participants as seen was largely unfriendly our study however never explored the coping strategies of the spouses and significant others challenges with a poor obstetric referral system in south western uganda are not only limited to women health care provider perspectives of the obstetric referral system in south western uganda revealed several constraints that range from inconsistencies of ambulance and anesthesia services electric power medical supplies no communication prior to referral support supervision harassment by colleagues and no feedback from mrrh to lower health facilities 61 these hcps suggest that staffing levels should be increased this could address the problem of hcp absenteeism in the event that some health centers are closed to service provision when their only staff is off duty for whatever reasons increasing the resources at the health provider level is important in achieving international targets for maternal and neonatal health outcomes and for bridging inequities in access to essential maternal and newborn healthcare 62 strengths of the study the study documented views of the individuals that interface with the health care system themselves this firsthand information is important to policy influencers for maternal health services interviews were conducted shortly after stabilization while the respondents were still in hospital this ensured that the nearmiss experiences were still fresh in their memory most studies around the obstetric referral explored the views of health care workers where women have been are involved studies are usually describing care at the final referral destinations not experience along the entire referral pathway or have been done elsewhere the current study adds the womens perspective in rural south western uganda to literature limitations of the study interviewing these women when they were still hospitalized with fresh memory of some traumatizing events like loss of babies to birth asphyxia loss of wombs to hysterectomy and development of vesicovaginal fistula led to emotional breakdown interviews for those women who got emotional breakdown were rescheduled or completed by their support persons in the case of those with eclampsia and could not narrate their ordeal after onset of a status eclampticus the number of women interviewed from a few referring health centers was relatively small to give comparable results we hope that duplication of this study with more participants and referral centers could produce more comparable results study implications overall our study reveals rampant negative experiences for women along the obstetric referral pathway for rural south western uganda due to poor socioeconomic status of women in labour and health system organizational discord this will derail the country efforts at achieving sustainable development goal 3 achieving good health and wellbeing for everyone including good maternal health who advocates for positive postpartum experiences but these cannot be realized with the physical and emotional morbidity experienced following these nearmiss events conclusions in conclusion our study has revealed that the numerous individual community and health system barriers to referral aggravated the negative experience of having an obstetric emergency and later being referred for care participants experienced delay in receiving emergency obstetric care poor quality of care the process was financially draining and they developed complications the warranted prolonged hospitalization womens interface with the current obstetric referral pathway in southwestern uganda reveals that the latter is wanting a prior study shows that health care providers are equally constrained by the health care system multisectoral concerted efforts will be handy to expedite improvements in emergency obstetric referral for western uganda by addressing the prevalent multifaceted challenges recommendations from the narratives of these participants it can be deduced that service improvements which address userviews are important to impact on health seeking behavior and utilization the health care system needs to focus on improvements in obstetric referral pathways so as to ensure a better continuum of care from the communities to health facilities nurses and midwives need to adhere to the ethical code of nursing conduct improving providerclient communication and relationship in order to heal the tainted nursing image and improve public opinion this will increase demand for nursing services and skilled obstetric care in particular labour care guide use needs to be emphasized so that labour complications can be recognised early for timely referral since some of the participants developed complications like obstructed labour while already at health facilities job aids and tools proper execution of obstetric referral should be develop and disseminated the ministry of health should improve the staffing norms at health facilities so that there are enough doctors and midwives to run the health units when some are off duty for whatever reasons to address the problem of absenteeism consistent logistical support in form of emergency drug stocks funds to fuel hc electric power generators sterilisation of instruments and fuel for ambulances is suggested for lower hcs so that multiple client transfers and third delays are mitigated the available operating theatres at lower health facilities if equipped and are more functional will save women multiple referrals birth planning and emergency preparedness campaigns should be mounted for pregnant women so that they are guided to seek timely care to avoid delays factors responsible for health care provider absenteeism in south western uganda should be explored training healthcare providers in respectful maternity care may improve both quality of care and positive patient experiences hcps may benefit from refresher sessions on customer care teamwork and proper procedures for execution of obstetric referral an implementation study to explore strategizes to improve the obstetric referral pathways for rural south western uganda and parts of central uganda is suggested data availability these are available from corresponding author upon reasonable request and with approval from the research ethics committee abbreviations supplementary material 1 authors contributions hn conceived designed the study and collected data jn hg and dk oversaw all study activities right from proposal development data collection reading the transcripts verification of data and data analysis and report and manuscript writing hn made the first draft of the manuscript all authors read revised and approved the final version of the manuscript funding the research reported in this publication was supported by the staff capacity development scheme fund of mbarara university of science and technology which supports staff education competing interests the authors declare that they have no competing interests

background lifethreatening obstetric complications usually lead to the need for referral and constitute the commonest direct causes of maternal deaths urgent management of referrals can potentially lower the maternal mortality rate we explored the experiences of women referred with obstetric emergencies to mbarara regional referral hospital mrrh in uganda in order to identify barriers and facilitating factorsthis was an exploratory qualitative study indepth interviews idis were conducted with 10 postnatal women and 2 attendants as key informants we explored health system and client related factors to understand how these could have facilitated or hindered the referral process data was analyzed deductively employing the constructs of the andersen healthcare utilization modelwomen experienced transport care delays and inhumane treatment from health care providers hcps the obstetric indications for referral were severe obstructed labor ruptured uterus and transverse lie in advanced labor eclampsia and retained second twin with intrapartum hemorrhage the secondary reasons for referral included nonfunctional operating theatres due to power outages unsterilized caesarian section instruments no blood transfusion services stock outs of emergency drugs and absenteeism of hcps to perform surgery four 4 themes emerged enablers barriers to referral poor quality of care and poor health facility organization most referring health facilities were within a 3050 km radius from mrrh delays to receive emergency obstetric care emoc led to acquisition of inhospital complications and eventual prolonged hospitalization enablers to referral were social support financial preparation for birth and birth companions knowledge of danger signsthe experience of obstetric referral for women was largely unpleasant due to delays and poor quality of care which contributed to perinatal mortality and maternal morbidities training hcps in respectful maternity care rmc may improve quality of care and foster positive postnatal client experiences refresher sessions on obstetric referral procedures for hcps are suggested interventions to improve the functionality of the obstetric referral pathway for rural southwestern uganda should be explored

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hypotheses alienation theory and work area the original meaning of the word alienation in english refers to a process in which people become unfamiliar with the world they live in and it encompasses connotations of estrangement detachment separation rule by alien forces and domination by others 18 in philosophy it is generally translated as alienation which refers to a state in which the opposing object is gradually separated from the subject in its activities thereby forming an external alien force against the subject 19 in sociology it refers to the separation of the individual from the main aspects of his society in economics it refers to the various antagonistic relationships that people have in the economic field 2021 in the psychological sense alienation was first used by marx in his economic and philosophic manuscripts of 1844 and marx elaborated on the theory of alienation in his works he noted that alienation is a complex concept that includes the two meanings of depersonalization and social estrangement 22 due to the influence of social changes and urban industrialization the original harmony between people and their living environment has been lost resulting in a sense of alienation in modern people the most striking thing about the theory of alienation is that it points out peoples social alienation from the perspective of human nature that is the loss of human nature leads to the generation of social separation the traditional marxist viewpoint emphasizes that labourers are objectively exploited and lack a sense of control and points out the subjective sense of powerlessness and selfseparation of labourers therefore the generation of alienation in labourers involves both subjective and objective factors subsequently many scholars have refined marxs theory of alienation and expanded the concept in the field of management psychology researchers focus on the alienation between employees and work which is called work alienation work alienation as a type of alienation reflects and is consistent with the theoretical origin of alienation theory and its core theoretical foundation emphasizing the complex relationship between employees and their working environment 23 in the field of organizational behaviour researchers suggest that work alienation essentially reflects that the needs of employees are not satisfied by their work and the source of alienation lies in the gap between the objective work situation and the employees values ideals and hobbies 124 seeman 8 conceived work alienation in five dimensions from the perspective of social psychology labour alienation powerlessness value alienation selfalienation and social isolation the concept of social isolation refers to the loss of close contact with others the collective and society from the perspective of the external environment it explained the impact of alienation from the environment on individuals work alienation is not limited to individual psychological analysis but is also closely related to the community location or governance environment regarding the core concept of selfseparation franks and marolla 25 further divided alienation into three aspects despised self disguised self and separated self karasek 26 pointed out that the separated self could best represent the core of work alienation ie such separation within the work context and further suggested that this separation may be caused by a lack of intrinsic rewards for work or by a lack of support and cooperation from the external environment 27 work area is a concept in organizational management and refers to the division and setting of workplace according to its different functions and roles in an attempt to improve work efficiency and safety 28 as work area is mainly used for the division of internal areas and arrangement of facilities it focuses on a reasonable and coordinated relationship between work environment and human body structure function and psychology from the perspective of physical characteristics and human engineering to render a workplace suitable for the demands of peoples physical and mental activities and improve work efficiency 29 apart from the division of work areas inside an organization work area also involves the characteristics of the organizations external environment that are present in the workplace 30 the concept of work area is macroscopically classified from the perspective of social characteristics based on the factors in an employees workplace such as its community environment population distribution or governance model china has always been a country with a dichotomy between urban and rural areas even within a city there is a natural distinction between the centre and the suburbs this division is primarily a classification of geographical administrative division moreover this geographical classification is based on the social characteristics and population density of a focal region as well as its grassroots community governance model as community frontline workers grassroots judicial administrators cannot achieve their tasks without community support the separation from the community environment will lead to a rise in their work alienation according to the social structure separation in chinas urbanrural dichotomy the difference in the location of a community makes a significant difference in the mode of governance between the stranger society and the acquaintance society 31 different regions reflect different community environmental cultures and governance models and provide different community support compared with that in the suburbs the community environment in the central districts is more complex making the work more difficult and providing less support to workers in it 4 previous studies on work alienation regarding both corporate and public employees have focused only on internal environment such as organizational centralization 432 interpersonal relationships within an organization 3 and organizational red tape 33 less attention has been given to research on the work alienation caused by the external environment of the organization based upon organizational location additionally most of the current research on work alienation is oriented towards psychological explanations while ignoring sociological explanations of the external community environment within chinas dualistic urbanrural structure of society this study has classified work area into two types from the perspective of the social feature of the external environment of the grassroots judicial offices central districts and suburbs since grassroots judicial administrators work in different areas they will receive different community support under different community governance models which will have an impact on the degree of their work alienation thus hypothesis 1 is as follows h1 the work area affects the work alienation of grassroots judicial administrators in which workers in the central districts have higher work alienation than workers in the suburbs other influencing factors of work alienation employees work alienation is affected by many factors mottaz 11 pointed out that the working environment has a significant effect on work alienation and it is the most important of the many influencing factors indeed its influence is stronger than that of employee background factors 34 kohn and schooler 35 concluded that work alienation includes both external and internal alienation external alienation includes a lack of precise supervision objective work factors etc and internal alienation includes work complexity monotonicity etc in the same organization different work contents determine the complexity and monotony of work to a certain extent especially in a highly hierarchical organization work content that focuses only on complicated rules and procedures will greatly strengthen the sense of psychological powerlessness and meaninglessness 33 grassroots judicial administration includes internal affairs management comprehensive social governance criminal correction and peoples mediation internal work mainly refers to internal affairs management in the judicial office and the completion of the relevant administrative work of maintaining social stability assigned by the judicial administrative organs at higher levels and the township peoples government such as form summary material sorting or law enforcement inspection such work content is trivial and complex repetitive and monotonous comprehensive social governance refers to the organization of publicity and education on the rule of law and the provision of grassroots legal services peoples mediation mainly refers to assisting local governments in resolving and mediating disputes among community residents criminal correction refers to the implementation of community correction resettlement help and education of former prisoners the latter three types of work content involve more contact with community residents where grassroots judicial administrative workers have more leeway and freedom to decide working form and working method if a staff member is responsible primarily for administration or the internal affairs of the judicial office he or she must master complicated work procedures and there is little room for him independent decisions thereby increasing work alienation h2 work content affects work alienation workers engaged primarily in routine work have higher work alienation than professional workers that is grassroots judicial administrators who are in charge of internal work have higher work alienation than other workers position level can also affect employees work alienation the higher their administrative level is the more opportunities there are for employees to participate in decisionmaking and make independent decisions 36 amid the same degree of organizational power centralization the higher an individuals position is the more work autonomy he or she has thereby reducing work his or her alienation 432 h3 position level affects work alienation the higher the administrative level the lower the work alienation in addition to work environment and work characteristics numerous studies have shown that the personal background of employees also has an impact on work alienation gender and age have an effect on employees work alienation as age increases womens work alienation increases while mens work alienation decreases 37 employees with a high level of education and professional mismatch tend to have higher work alienation 9 and the fit between employees professional education background satisfies the job requirements and affects work alienation 14 in the case of grassroots judicial administrators their work involves many basic legal tasks such as law popularization those with a legal professional background are more competent in these work tasks and they have lower work alienation than those with a nonlegal professional background additionally overqualification increases employees work alienation and leads to emotional exhaustion 38 grassroots judicial administrative work is complicated and repetitive and the greater the number of years is the more likely professional burnout and excessive competence are which in turn enhances work alienation in this study the sociodemographic factors of grassroots justice administrators are used as control variables and the effects of work environment and work characteristics on work alienation are examined carefully in summary previous research rarely involves social management workers most studies on work alienation focus on manual and technical workers 2439 such as fast food workers 9 truck drivers 40 industrial workers 41 airline staff 5 pharmacy salespersons 42 midwives 43 it technicians 3 or university faculty 6 few studies however have been conducted on work alienation among grassroots judicial administrators such studies have mostly explored the influencing factors on work alienation via employees personal characteristics and internal organization environment neglecting the impact of the external environment of an organizations location grassroots judicial administrators directly participate in community governance social services and administrative law enforcement therefore exploring the relationship between work area and work alienation can theoretically provide a new perspective for observing and explaining the work situation of grassroots judicial administrators while practically enabling organizations to respond to work alienation and apply positive coping strategies for it which is the main purpose of this study methods study design this study is an empirical analysis of the work alienation of grassroots judicial administrators based on the literature review considering the research teams relationship network and the availability of research objects all grassroots judicial administrators in guangzhouwere taken as the sampling frame and stratified random sampling and structured questionnaires were used to conduct a crosssectional quantitative study the object of this study is grassroots judicial administrators it should be noted that the factor of internal organizational environment characteristics is not covered in this study the focal grassroots judicial offices are positioned within a highly hierarchical system with extremely high homogeneity in terms of organizational structure internal working environment and work norms and there are basically no differences across offices meanwhile the relationship between coworkers and work atmosphere inside a judicial office may impact work alienation as each judicial office usually has 5 employees who are very close to each other the relationship between coworkers and work atmosphere reflects the hierarchy in their judicial office more than the circumstance of individual judicial administrative workers moreover the questionnaire does not interrogate the relationship between coworkers and work atmosphere inside their judicial office to reduce the sensitivity of test questions and improve the probability of successful interviews therefore their physical environment and coworkers relations within their grassroots judicial offices were excluded this study also focuses on the guangzhou area so all the judicial administrators are in the same sociocultural context this study is exploratory in nature focusing on exploring the relationship between the work area work characteristics of grassroots judicial administrators and their work alienation setting and participants guangzhouis at the forefront of chinas reform and openingup it is a superlarge city and a pilot area for chinas judicial administrative reform compared with the typical absence of grassroots judicial offices at the village and township level in rural areas of other cities the urban and rural areas in the jurisdiction of guangzhou are fully covered by grassroots judicial offices thus a complete picture of the focal grassroots judicial administrative staff can be more effectively illustrated through better representativeness the exploration of the work alienation of the judicial administrators in guangzhoucan provide corresponding guidance for the country taking all grassroots judicial administrators in guangzhouas the sample frame the sample survey was carried out in guangzhoufrom june to august 2019 the grassroots judicial administrators selected in this study must meet all the following requirements 1 they must be formal civil servants excluding government employees who are not civil servants 2 their personnel appointment must be in the judicial bureau of a district in guangzhou with civil servants whose personnel appointment is in another government department or who are seconded to or temporarily working in a judicial office being excluded 3 they must currently work in a grassroots judicial office judicial administrators currently working in bureaus are not grassroots personnel and are excluded from this study the stratified systematic sampling method was used the number of judicial administrative personnel varies according to the total population of the subdistrict or town where each judicial office is located generally between 3 and 8 in this survey if the number of personnel in a judicial office was ≤ 5 2 were selected if it was 5 3 were selected first based on the number of judicial offices in each district 44 a certain number of judicial offices were randomly selected in each district second 23 grassroots judicial administrators were randomly selected from each selected judicial office according to their internal serial numbers in the office third the investigator conducted a questionnaire survey with the selected grassroots judicial administrators in the judicial office the questionnaire survey covered 11 districts and 132 judicial offices in guangzhou a total of 300 questionnaires were distributed and 297 were retrieved of which 288 were valid thus the valid questionnaire response rate was 96 these sample data cover the judicial offices of all districtlevel administrative units in guangzhou with good representativeness and universality ethical considerations this study involving human participants was reviewed and approved by the ethics committee of the school of public administration guangzhou university and procedures were conducted in accordance with the declaration of helsinki the relevant ethics protocols were strictly observed throughout the questionnaire survey process before the commencement of the questionnaire survey the investigator briefly introduced the purpose of the survey the principle of anonymity and voluntariness all respondents provided written informed consent to participate in this study if a grassroots judicial administrator refused to accept the survey he or she would be replaced by the administrator with the next internal serial number to the right the questionnaire was completed by the respondent or was completed via questionandanswer the questionnaire was completed in a relatively independent environment with the investigator providing timely onsite answers to interviewees questions after the questionnaire was completed the investigator immediately retrieved it to ensure the confidentiality of each respondents information variables work alienation scale work alienation in this study refers to the selfseparation caused by work and it also refers to the degree to which work does not provide inner satisfaction the selection of the work alienation scale was based primarily on the following factors it is recognized in academic circles and widely used with good reliability and validity it has been tested in the chinese context and translated into chinese the scale refers to the work alienation scale prepared by seeman 8 which is based on marxs theory of alienation in the subjective sense and measures the separated self focusing on employees separation within the scope of work the seeman scale has been widely used in crosscountry work alienation research and comparisons and has become one of the classic paradigms for the development of the work alienation measurement scale 45 yang et al 21 and robinson et al 22 translated the work alienation scale into chinese this scale is a onedimensional scale measuring inner work alienation the scale includes a total of 7 questions which measure whether their work is regarded by the employees as highly intensive challenging creative focused worthy of persistence autonomous or boring the scale adopts a dichotomous response option and each question is scored as 0 or 1 after reverse conversion of some items the total score of the scale is between 0 and 7 the higher the score is the stronger the work alienation based on the data from 288 grassroots judicial administrators in guangzhou the 7 scale items were used for itemanalysis and all passed the kr20 coefficient of internal consistency reliability of the scale was 0537 although the internal consistency reliability of the scale did not reach 07 the scale reliability was 051 and 050 in us and french samples respectively 46 so the reliability of the scale is acceptable there was a strong negative correlation between the work alienation scale and the work engagement scale 47 so the scale has good discrimination validity work area the work area is a dichotomous variable divided into 0 suburbs and 1 central district according to the location of the administrative area in which the judicial office is located in guangzhou according to guangzhous 2019 urban administrative division map 48 and the 2020 guangzhou statistics yearbook 49 the districts of huadu zengcheng nansha conghua and baiyun are the suburbs and the six districts of haizhu huangpu panyu yuexiu tianhe and liwan are the central districts the suburbs have a much lower population density than the central districts after calculation the population density of permanent residents is 673504km 2 in the six central districts and 107353km 2 in the five suburban districts in addition in terms of the community governance model the suburbs are mainly dominated by village committee autonomy while the central district mainly depends on community committees these districts are significantly different from the central districts in terms of population density and governance mode work characteristics the main work responsibilities and administrative post level were included according to the judicial offices responsibilities grassroots judicial administrators have nine major tasks based on the nature of the work and the similarity of the content this study categorizes work content into four categories 1 internal work 2 comprehensive social governance 3 criminal correction and 4 peoples mediation respondents may be responsible for multiple types of work tasks this study asks about and records the type of work tasks that respondents spend the most time and energy on according to the provisions of the national civil service law and the administrative unit level of subdistrict and town judicial offices in guangzhou the administrative post levels can be divided into four levels from low to high 1 clerk 2 officer 3 associate chief officer and 4 chief officer and above sociodemographic variables the gender age education level professional background and working years of grassroots judicial administrators were included gender is a dichotomous variable 0 male and 1 female age is the full year of age of the respondent at the time of the questionnaire survey education level is a dichotomous variable 0 junior college education and below and 1 undergraduate education and above professional background was originally a fillintheblank question and the respondents indicated their majors at different educational stages in turn if a respondents major was law at any stage of education professional background is coded 0 otherwise it is coded 1 working years refers only to the number of years the respondent has been engaged in grassroots judicial administration that is the respondents work time in the judicial office was counted the respondents time spent working in the judicial bureau and on other types of work was excluded sampling information a total of 288 grassroots judicial administrators were interviewed of which 203 were males accounting for 705 and 85 were females accounting for 295 the age range was 20 to 57 years old with an average age of 380 years among the grassroots judicial administrators 206 had received an undergraduate education or above accounting for 715 and 82 had received a junior college education or below accounting for 285 in terms of professional background 199 graduates majored in law accounting for 691 and 89 graduates did not major in law accounting for 309 the graduates not majoring in law majored primarily in economics administrative management and humanities and social sciences the number of years worked in the grassroots judicial administration was between 1 and 33 years and the average working time was 933 years this was strongly positively correlated with age showing that the number of years grassroots judicial administrators have worked in grassroots administration increases with age and that the team is stable with vol 1234567890 in summary most grassroots judicial administrators are men they are generally middle aged their education level is relatively high nearly threequarters have received undergraduate education and almost all of them have received higher education and most studied law or economics management humanities and social sciences etc currently the personnel pool is stable and has a reasonable distribution in terms of administrative levels and rich experience in judicial administration the total number of personnel in the central districts is slightly higher than that in the suburbs statistical methods statistical analysis was performed using spss 240 software first descriptive statistics were used to reveal the status quo of grassroots judicial administrators work alienation second variables such as gender and age in relation to work alienation were separately analysed in terms of variance or correlation to explore the relationship between each variable and work alienation separately third work alienation was taken as the dependent variable work characteristics as the firstlevel independent variables and work area as the secondlevel independent variables next ordinary least squares linear regression analysis was conducted to further explore the factors significantly associated with work alienation while controlling for sociodemographic factors since the data of this research were derived from a questionnaire sampling survey regression analysis was finally conducted for all variables common method variance may lead to systematic measurement errors and further skew the estimation of the true relationship between variables 50 therefore the existence of cmv is tested for prior to official data analysis harmans one factor method is used to include all factors in this paper into factor analysis where 1 common factor is set to be extracted the analysis shows that the explained variation caused by 1 factor is 16987 thus cmv does not exist in the data collected in this research with 50 51 as the judgement criterion results status quo of work alienation after statistical analysis of items and total scores of work alienation as table 2 shows the problems of high work intensity and lack of autonomy among the grassroots judicial administrators were the most prominent with more than twothirds of the respondents reporting these problems in comparison the problems of lack of challenge and boring were not prominent the total mean of work alienation 250 and the standard deviation 1512 the overall work alienation of the grassroots judicial administrators was thus at a moderately low level with work alienation as the dependent variable before the regression analysis a histogram was first drawn to test its normality skewness 0737 kurtosis 0655 the kolmogorovsmirnov test passed and the normality of the data distribution was acceptable the independent variables in relation to work alienation were separately analysed in terms of variance or correlation in table 3 female grassroots judicial administrators had slightly higher work alienation than men but there was no significant difference for those with different professional backgrounds work table 1 status quo of the grassroots judicial administrators a the mean of dichotomous variable indicates the percentage of category assigned with higher value such as 1 female and 0 male and the mean of gender 295 indicating that women account for 295 b the category in parentheses is assigned 1 c the work responsibilities and administrative levels have undergone dummy variable conversions from fourchoice category variables to four dichotomous variables with values of 01 responsibilities and administrative levels there was no significant difference in their work alienation education level and work area were significantly related to work alienation those with a junior college education and below had significantly higher work alienation than those with an undergraduate education and above t 3431 p 001 those working in the central districts had significantly higher work alienation than those working in the suburbs t 5599 p 0001 age and years worked had a significant positive correlation with work alienation and the pearson correlation coefficients were 0131 and 0135 respectively indicating that the older the age and the greater the number of years worked the stronger the work alienation was hierarchical regression analysis with work alienation as the dependent variable and gender age education level professional background and working years as control variables a regression analysis was performed from the analysis results of model 1 in table 4 it can be seen that when controlling for other variables gender and professional background had no significant effect on work alienation and the effect of age on work alienation became negligible education level had a significant effect on work alienation as well as the number of working years the nonstandard regression coefficient b 0662 p 0001 indicating that the work alienation of the grassroots judicial administrators with an undergraduate education or above was lower by 0662 points on average than that of those with a junior college education or below taking the work characteristics factors as the firstlevel independent variables and including them in the regression analysis model 2 shows that after the inclusion of work characteristics education level still had a significant effect on work alienation b 0627 p 001 gender age and professional background still had no significant correlation with work alienation taking the internal work of the judicial office as a reference there was no correlation between work responsibilities and work alienation in the same way administrative level also had no effect on work alienation finally work area as the secondlevel independent variable enters into regression model 3 the work area of the grassroots judicial administrators had a significant effect on their work alienation b 0917 p 0001 with the work alienation of multicollinearity of the independent variables in model 3 was further tested and the variance inflation factor values of the independent variables were between 1082 and 4410 and all were less than 5 indicating no serious collinearity among the independent variables 52 finally the explanatory power of the models was tested variable discussion this study found that the grassroots judicial administrative personnel pool has a relatively reasonable overall structure and high professional quality and is relatively stable 11 and such differences are also reflected in the fact that the same factors have different effects on work alienation among different types of labour groups there is a significant correlation between education level and the work alienation of grassroots judicial administrators although education level is entered into the model as a control variable it still provides some useful insights in this study the higher the education level was the lower the work alienation of the grassroots judicial administrators and vice versa dipietro and pizam 9 conducted a study on work alienation among employees and managers in the american fast food industry and found that education level has a significant effect on work alienation but there is a positive correlation between the two the higher the education level is the higher the work alienation to understand these two completely opposite research findings it is necessary to explore and explain the work ability needs of different types of labour groups 53 for manual labour groups such as fast food workers and truck drivers there are no requirements to have a high level of education and employees with higher education levels cannot express their knowledge value through their work and are more likely to have a sense of powerlessness and value alienation thus their work alienation is positively correlated with their education level grassroots judicial administrators need to manage the intricate legal affairs of local communities carry out highly professional criminal correction work and complete a series of judicial administrative tasks they need a wealth of professional knowledge in law sociology and psychology a high education level makes it easier for them to execute grassroots judicial the area where the judicial office is located has a significant effect on the work alienation of grassroots judicial administrators the work alienation of the judicial administrators working in the suburbs is significantly lower than that of those working in the central districts according to the investigation the reasons are as follows the first issue is the complexity of the work the density of permanent residents in the central districts is much higher than that in the suburbs in regard to the judicial administrative work of a certain community in an area high population density indicates that population service management and legal affairs in the community are more complex and that more grassroots judicial administrative work needs to be carried out 54 thus the work pressure and work intensity are naturally higher than in areas with lower population densities the second issue is the differences in social governance models between suburban and central districts regarding the social management work and legal services directly performed by grassroots judicial administrators many tasks need to be carried out in cooperation with grassroots political organizations in the area in the central districts community governance is mainly carried out through the subdistrict office and residents committee in the suburbs it is mainly carried out through the town government and villagers committee the village is an acquaintance society and each village has established local rules that have strong binding and controlling power over the villagers 55 on the other hand a subdistrict is often divided into communities of different numbers with high heterogeneity among community members these communities are societies of strangers for historical and social reasons unique to china villagers committees and villagers autonomy have a longer history and a more stable form while residents committees are experiencing difficulty achieving autonomy at present 56 grassroots judicial administrators in the suburbs can more easily secure villagers autonomous and conscious cooperation when carrying out judicial administration and the work pressure in the suburbs is lighter in the central district governance model however the community composition is more complicated and community members are not connected by family ties but are atomized individuals who gather from different places to make a living and do not know each other grassroots judicial administrators experience less cooperation from residents in the central districts and it is difficult to carry out their work so their work pressure and work alienation increase accordingly although fedi et al 36 pointed out that the different positions of employees in the organization have different effects on their work alienation in the civil service system of the grassroots judicial administration the administrative level and work responsibilities are not related to work alienation for grassroots judicial administrators the external environmental characteristics of their work are more significantly related to work alienation than to internal differences conclusion as an exploratory study this study adopts a crosssectional method which is its main limitation in addition this study measured only the relationship between the objective external work environment and work alienation it did not address the relevant subjective psychological influencing factors such as selfesteem 57 or sense of achievement 58 further studies can consistently examine the effect of the external environment after considering subjective factors for grassroots judicial administrators high work intensity and lack of autonomy at work are the most prominent manifestations of their work alienation to reduce work alienation among grassroots judicial administrators specific followup training and continuing education should be provided to improve their professional knowledge level for those in the central districts it is beneficial to strengthen the contact and interaction between the grassroots judicial offices and the local government organizations and community residents and promote the selforganization ability of communities in the central districts to improve the overall quality of grassroots judicial administrative work and reduce work alienation data availability the datasets generated and analysed in the present study are available in the figshare repository doi org 10 6084 m9 figsh are 19632 588 the personnel working in the central districts being higher by 0917 points on average than that of those working in the suburbs it can be seen from the standardized regression coefficients of the independent variables in model 3 that the work area beta 0298 and the education level beta 0151 in the regression model so work area had a greater effect on work alienation than education level the applicable conditions of the model 3 regression model were tested the durbinwatson test value 0252 which is close to 2 indicating a very small possibility of autocorrelation among model residuals and that the observation data of the model can be regarded as independent of each other the model standardized residual histogram in fig 1 indicates that the model residuals are subject to a normal distribution in the residual scatter plot in fig 2 the model residuals do not change with the size of the model predicted values or the values of any of the variables and the residuals are randomly distributed above and below the 0 reference line with homogeneity of variance the casewise diagnostics method was used to identify strong influential points with none being found in the model the competing interests the authors declare no competing interests

work alienation refers to mental selfseparation from work and it is an integral reflection of workers and their work few studies have explored the association between work area and work alienation among grassroots judicial administrators a stratified sampling method was used to collect data from 288 grassroots judicial administrators in guangzhou to measure the overall status quo and work alienation in this group this study found that the current grassroots judicial administrative team has a reasonable structure high professional quality and rich grassroots work experience but a high level of work intensity mean 667 and a lack of autonomy mean 757 are prominent work area unstandardized regression coefficient b 917 is significantly related to work alienation when controlling for sociodemographic and work characteristic variables the closer the work area is to the city centre areas the higher the level of work alienation in addition education level also has a significant effect on work alienation the lower the individual education level is the stronger the work alienation the discussion focuses on the knowledge needs in grassroots judicial administrative work and the importance of the external working environment and further research implications are proposed work alienation refers to a mental state when the working environment does not meet the work expectations and needs of employees which leads to the isolation of employees from the work they are engaged in 1 it also refers to workers loss of purpose at work 2 as an important academic concept work alienation has long been used in research on many topics such as workers occupational psychology 34 occupational mobility 56 and interaction with their organizational environment 78 work alienation is the overall reflection of a workers relationship with the people organization society and environment surrounding his or her work it is affected by the individual characteristics of employees 9 psychological controls work characteristics 1 leadership styles 10 working environments 11 and many other factors in recent decades work alienation has been a focal topic in chinese sociology and psychology research 12 13 14 china is in a period of deepening social transformation with the acceleration of social changes the instability of the relation between workers and their jobs has increased after the 1990s the social function attributes attached to work such as housing childrens education and medical care were stripped away and work returned to the pure professional relationship itself in recent years 996 workers go to work at 9 am and return from work at 9 pm 6 days a week and other work cultures that represent highintensity work patterns have prevailed the distance between workers and their work is ever increasing and the problem of individual alienation caused by work has been widely commented on in academic and practical circles chinese grassroots judicial administrators are stationed in community judicial offices the judicial office is the most basic organization of the national judicial administrative authority and is the communityfacing agency at the town level subdistrict of the municipal district county judicial bureau responsible for the implementation of various grassroots judicial administrative tasks grassroots judicial administrators have the closest contact with the community and are responsible for resolving community conflicts advancing the rule of law in the community supervising offenders in community corrections and maintaining the harmony and stability of local society at present there are 40513 judicial offices in china and 128000 grassroots judicial administrators covering all towns subdistricts nationwide 15 domestic and foreign research has rarely paid attention to this unique and sizeable occupational group in the judicial system consisting of public securityprocuratoratecourtjudicial administration judicial administrative work is characterized by serviceability triviality and complexity relative to

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introduction as educational and occupational expectations have evolved many young people now face more obstacles to and longer delays in transitioning to adulthood as reflected in such markers as leaving the parental home completing school getting married and becoming a parent this transition coincides with important social status developments in which individuals are accruing education and skills for the work force as well as financial assets or debts that typically continue into later adulthood the accumulation of advantage and disadvantage during this period affects ones lifelong opportunities and resources and ones overall health and wellbeing although social status is widely acknowledged in social science research to be a multidimensional construct that varies over the life course few studies on young adults have used social status in this multifaceted and dynamic manner rather previous studies often use static indicators of parents status as a proxy or use single pointintime young adult status even though it is in flux furthermore researchers often operationalize social status using indicators of income and education that may have different meanings during the transition to adulthood single indicators can also mask potential heterogeneity in the processes of accumulating advantage or disadvantage as a result studies that use a single pointintime indicator of social status can draw misleading conclusions about the effects on various social and health outcomes with changing demographics and an elongated transition to adulthood there is a critical need for longitudinal studies to enhance our understanding of social status over this period the current study applies a personoriented approach of latent class analysis to study social status as a lifecourse construct during the transition to adulthood within the domains of economic and human capital this approach provides insight into how the status attainment process unfolds as individuals make this transition status attainment social status is defined as the relative position of individuals in a stratified society as characterized by economic capital and human capital economic capital refers to ones material resources like income and assets as means to procure further social status human capital captures ones knowledge and skills as means to gain social status status attainment refers to the processes by which initial social status or origin subsequently becomes social status over time or destination blau and duncans original status attainment model examined fathertoson occupational mobility in a variableoriented approach the wisconsin model of status attainment highlighted key social psychological and institutional factors in adolescence that mediate the effects of social origins on adult education occupation and income however variableoriented approaches to study these processes are often unable to detect subgroups with different status attainment processes which are better captured using a personoriented approach status attainment involves intergenerational and intragenerational processes that trace patterns of social stability and mobility in society in the early 20 th century intergenerational processes played a large part in determining ones social status such that individuals closely resembled their parents this stickiness of social status can limit opportunities for movement up or down the social ladder ones own achievements however provide an additional pathway for upward or downward mobility and both intergenerational and intragenerational processes are often in dynamic tension for instance although education has traditionally played an integral role in upward mobility intergenerational effects of increasing economic inequality have in recent decades led to more stickiness in educational attainment since the transition to adulthood is a time when social status is in flux an individuals experiences of accruing status during this transition should be considered in conjunction with the potential advantages or disadvantages bestowed by the previous generation in addition previous studies often restrict status attainment models to a single dimension of social status and overlook the conceptual differences between types of capitals and nuances within capitals that contribute to ones social status specifically economic capital plays a different role in determining ones social status than human capital material resources such as income can elevate ones living conditions and ability to purchase goods that symbolize higher social status furthermore experiences of poverty and wealth signal accumulated disadvantages and advantages that are not captured by a single measure of income in contrast human capital such as education and occupation represent ones skills ability and intellect that are associated with a particular lifestyle social network or environment of higher or lower social status characteristics such as vocational training or time spent in school or work provide a more complete assessment of the human capital experiences during the transition to adulthood these distinctions highlight the importance of investigating both economic and human capital but draw attention to the markers that go beyond income and education to capture diverse aspects of social status that may be especially important during the transition to adulthood lifecourse perspective the lifecourse perspective provides an optimal framework for studying status attainment over the transition to adulthood its themes of time and timing trajectories linked lives and human agency serve as guiding principles for this study accruing maintaining and losing social status are viewed as key developmental processes that fit within the lifecourse framework applying a lifecourse perspective identifies several limitations of previous research about the evolution of status attainment first conventional markers of social status eg education occupation incomeare sensitive to life stage making it essential to study time and timing for example equating initial social status with parents education or income may be appropriate for adolescence but not young adults and income among young adults may fluctuate considerably especially when individuals are still in school making the timing of educational attainment a key consideration to assess intergenerational and intragenerational mobility these traditional markers should be captured over repeated time points in addition nontraditional markers provide a broader assessment of status that may be especially relevant for some subgroups of the population such as low income families furthermore involvement in school and at work should be considered during this time given that individuals are accruing status at varying rates for these reasons the current study uses longitudinal data with a diverse set of social status measures to provide a deeper assessment of the status attainment process during the transition to adulthood second individual decisions and the timing of early life events can impact future status attainment by forming status attainment trajectories leading to the accumulation of advantages or disadvantages this embodies the concept of human agency in decision making which refers to the choices individuals make given the opportunities and constraints in their world for example early entry into adult social roles has longterm social status effects and creates a buildup of subsequent transitions such as early exit from school or early entry into work these early transitions have been linked to relatively low subsequent social status delayed entry into adulthood also has longterm social status effects and leads to a buildup of transitions such as further dependence on parents delayed entry into work postponement of marriage and parenthood these delayed transitions have been linked to relatively high subsequent social status this social bifurcation of the transition to adulthood demonstrates that although individuals are active agents in the status attainment process the consequences of early decisions have compound effects on future trajectories third the role of parents is an application of the lifecourse theme of linked lives that is critical to the transfer of advantages and disadvantages from one generation to the next the social status and resources of ones family of origin can aid or deter status attainment compared to individuals from advantaged families individuals from disadvantaged families have fewer resources and capacities to navigate the various transitions of obtaining secondary education entering the work force and forming families furthermore some individuals remain financially dependent on parents while others financially contribute to parents these patterns are evident for both economic and human capital but with varying returns on ones social status for instance economic capital transfers may provide more immediate effects on status whereas human capital transfers may be more intangible and longterm finally social and economic inequality across parents creates different starting positions for status attainment among offspring in this manner the social status of parents impacts that of their sons and daughters as do the choices these young people make with regard to transitions into adult roles and trajectories of economic and social capital the current study distinct lifecourse patterns of status attainment from adolescence to early adulthood are modeled by applying a personoriented analytic approach to survey data from the national longitudinal study of adolescent health specifically lca is used to group individuals into classes based on multiple indicators of social status in the domains of economic capital and human capital assessed at three times points during the transition to adulthood given the importance of both the intergenerational transfer of social status and individual agency we expect to find patterns of stability for both high and low social status and mobility both upward and downward these patterns are thought to be present for both economic capital and human capital although economic and human capital are distinct they should correspond to each other to some degree because they are both forms of social status such that low economic capital will be associated with low human capital and high economic capital with high human capital furthermore these patterns are expected to be linked to the bifurcation of adult social role trajectories with low status groups being more likely than high status groups to be married and have children by early adulthood methods data add health is an ongoing study of a nationally representative sample of 7 th 12 th grade us youth during the 199495 school year who were followed into adulthood a multistage stratified cluster design was used to select 80 high schools and 52 feeder schools more than 90000 students participated in an initial schoolbased survey a core inhome sample was drawn from the schoolbased sample with oversamples based on ethnicity genetic adoption status and disability this core sample then completed a 12 hour survey at home and were surveyed again in 1996 200102 and 200809 parents were interviewed at w1 the current studys analytic sample is restricted to respondents with w1 w3 and w4 inhome and w1 parent interviews w2 data are not used given the close proximity to w1 and lack of followup with w1 high school seniors members of small racialethnic groups were excluded because there are too few for analysis and the category is too heterogeneous to be meaningful cases without a sample weight were excluded the final analytic sample is 8977 data are weighted and standard errors are adjusted for the complex sample design weighted sample characteristics are presented in table 1 gender composition is fairly equal and the majority of respondents selfidentified as whites with far fewer blacks and hispanics and even fewer asians the mean age in adolescence is 15 young adulthood is 21 and adulthood is 28 due to higher attrition among respondents with lower income and education the results may be biased towards higher income and education although sample weights adjust for this factor this study was approved by the university of california los angeles human subjects protection committee measures economic capitalthis dimension of lifecourse social status assesses financial resources financial strain and wealth with a total of 20 measures financial resources multiple measures were used to assess financial resources including income public assistance and family transfers annual household income in dollars from w1 was used to assess adolescent financial resources a large percentage of missing for w1 income was taken into consideration by using fullinformation maximum likelihood estimation personal income in dollars from w3 and w4 was included for young adult and adult resources to address inflation income was standardized to 2008 dollars it was topcoded at the 99th percentile and squareroot transformed to improve the distribution past year receipt of public benefits at each wave captured formal financial sources past year family transfers at w3 and w4 assessed informal sources respondents were asked whether parents helped to pay or gave them 50 or more for living costs in w4 only respondents were asked whether they helped to pay or gave 50 or more for parents living costs financial strain financial strain in the past year was included from adolescence young adulthood and adulthood no health insurance was also captured from each wave wealth a total of 5 measures were used to capture wealth home ownership was measured in w3 and w4 respondents were asked their total household assets and total household debt at w4 dollar values were assigned to assets and debts by recoding categorical values to the midpoint of the interval to capture additional intergenerational financial transfers respondents were asked whether they received family help to buy or remodel a home in w4 human capitalthis dimension of lifecourse social status assesses knowledge and skills with a total of 15 measures education four parental measures and five respondent measures captured education in w1 respondents were asked how far did your go in school parents education was categorized into less than high school high school degreeged some college college degree and graduate or professional school two binary variables captured whether a mother and father were present in the household during adolescence since respondents were at least 18 years old in w3 it was assumed that they were no longer in high school and thus an indicator for high school degree or ged by young adulthood was included two binary items accounted for current school status in w3 and w4 an additional w3 indicator documented receipt of vocational training educational attainment at w4 had the same categories as parents education occupation a total of 6 measures captured parent and respondent occupational characteristics type of occupation captures skills set and presumed prestige associated with a job using us census classifications w1 respondentreported parents occupation were categorized into five dummy variables of manual or blue collar sales service or administrative other professional professional or managerial and unspecified other in reference to not working since job changes are frequent in young adulthood w3 occupation was excluded at w4 respondents were classified into most recent or current job using the same dummy variables as parents to measure employment history and time spent at work respondents number of hours worked per week was included from w1 w3 and w4 work hours were topcoded at the 99 percentile a respondent was given a value of zero hours if no occupation was listed or they were not working at w4 transition to adulthoodfor young adulthood markers of living with parents currently in school fulltime work status ever married and having children were included for adulthood currently in school fulltime work status and having children were included adult marital status was categorized into two dummy variables of currently married and divorcedseparatedwidowed relative to never married the omitted reference category covariatesdemographic variables included gender age combined race and ethnicity construct and family structure these variables were selected because of the significant demographic associations with both to the transition to adulthood and status attainment statistical analyses this study applies a personoriented approach of latent class analysis for analyzing longitudinal data lca is a technique to identify substantively meaningful subgroups within the larger population this approach allows researchers to go beyond identifying the effect of a single variable on an outcome to understand patterns of a set of variables as a whole on an outcome it is especially beneficial for studying complex constructs such as social status lca is a nonparametric statistical technique that assumes that patterns among a set of observed variables are explained by an unmeasured latent variable with discrete classes where classes are groups with similar values on the variable set lca is similar to factor analysis except that the resulting latent variable is categorical with a multinomial distribution observed variables are assumed to be locally independent within each class such that any intraclass correlations or multicollinearity between variables are not an issue in lca whereas they are common and problematic in variableoriented frameworks respondents are assumed to belong to only one class in this study lca was used to identify the optimal number of latent classes and class sizecharacteristics a series of lca models was tested specifying 1 to 6 classes model selection was based on model fit statistics other model fit criteria were high class homogeneity and high class separation once the bestfit model was identified additional lca models were estimated adding covariates of demographic characteristics and transition to adulthood markers the statistical significance of the association between class membership and each covariate was assessed with a multinomial logistic regression models each covariate was statistically significant at a pvalue of less than 005 using loglikelihood ratio tests in sensitivity analyses respondents were assigned to a class based on their maximum predicted probability of class membership and covariates were compared across groups using conventional bivariate statistical techniques specifically chisquare tests for categorical covariates and ftests for continuous covariates these findings aligned well with the lca results for ease of interpretation the bivariate relationships are presented as proportions and means using these conventional methods descriptive statistics were conducted in stata version 120 and lca was conducted in mplus version 611 survey procedures in stata and mplus corrected for unequal probability of selection attrition and the complex sample design missing data in social status measures were handled using full information maximum likelihood estimation fiml assumes that data are missing at random however even if the mar condition is not completely satisfied fiml estimation can reduce bias while maximizing the number of observations results economic capital with each additional class the loglikelihood aic and bic values first decreased and then leveled off between 3and 6class solutions appendix a lmr test statistics also supported 3to 6class solutions however there were trivial class sizes in the 5and 6class solutions and itemresponse probabilities showed poor class homogeneity and poor separation these considerations point to a 4class lca model as having the most distinct groupings of economic capital the persistently disadvantaged group was characterized by accumulated disadvantages over the life course in adolescence the mean household income was substantially lower than the total sample personal income grew slightly from young adulthood to adulthood public assistance and not having health insurance were consistently high at each wave and home ownership was low relative to the sample overall despite receiving family financial support this group was the second highest in giving financial help to their families in adulthood the upwardly mobile group possessed characteristics of increasing economic capital from adolescence to adulthood in adolescence this group had the second lowest household income among the four classes by young adulthood this group represented the highest mean income and by adulthood the second highest financial strain public assistance and not having health insurance declined over time by adulthood almost half of respondents owned a home this group received little family financial support and was most likely to provide financial support to family in adulthood the downwardly mobile group had the second highest mean household income in adolescence however by young adulthood and adulthood personal incomes were the second lowest of all classes on average economic hardships gradually increased over time and only onequarter owned a home in adulthood a majority received family financial support in young adulthood and adulthood with little return to family in adulthood the persistently advantaged group was characterized by an economic environment of high incomes and little economic hardship over this period of the life course in adolescence the mean household income was the highest of any group and personal income grew substantially from young adulthood to adulthood over half owned a home in adulthood family financial support in young adulthood was highest across all groups but was lowest of all groups by adulthood this group was also likely to receive financial support for their home purchase but provided little support back to family in adulthood table 3 presents demographic characteristics for each economic capital group as defined by the highest predicted probabilities of class membership the persistently disadvantaged had more females blacks and hispanics than the persistently advantaged which had more males whites and asians males and hispanics made up higher proportions of the upwardly mobile group than the downwardly mobile group which had more whites and slightly younger persons the downwardly mobile had the youngest mean age in adulthood however the mean age for all groups is 279 which signals a young sample turning to the two types of capital table 3 also presents education as a representative human capital indicator for each economic capital group parents and respondents education were very similar within the persistently advantaged and disadvantaged groups when compared to parents respondents education levels were lower for the downwardly mobile group but higher for the upwardly mobile group when examining across economic capital groups the downwardly mobile had higher education levels than the upwardly mobile for the transition to adulthood markers also shown in table 3 the persistently disadvantaged had early adoption of adult social roles being most likely to have left the parental home and school and second most likely to be married by young adulthood having the highest proportion of those who have children in young adulthood and adulthood suggests early childbearing in contrast the persistently advantaged had patterns of delayed entry into adult roles in young adulthood a majority was still in school and few had married or had children by adulthood however the persistently advantaged had higher proportions of marriage than the persistently disadvantaged the upwardly mobile resembled the persistently disadvantaged with respect to early adoption of adult roles in particular fulltime work status marriage in this group however remained high in adulthood the downwardly mobile group was similar to the persistently advantaged except with higher proportions living at home in young adulthood and being in school in adulthood while they had a high proportion of never married compared to the persistently advantaged the downwardly mobile also had a higher proportion of being a parent human capital the loglikelihood aic and bic values and lmr statistic supported four or higher class solutions for lca models appendix b however the 4class and 5class solutions had large clusters in one class suggesting that a large proportion of respondents shared similar human capital characteristics although class prevalences were equally distributed in a 6class solution class separation was poor in that patterns were similar from one class to another class in the 5class solution class separation and homogeneity were good therefore a 5class model was selected as the bestfitting model table 4 shows the class prevalences and probabilities for this model class 1 persistently low class 2upward mobility with early entry to work class 3 upward mobility with continued schooling class 4downward mobility with early entry to work and class 5 persistently high similar to economic capital the persistently low made up the smallest human capital group a plurality of respondents falls into the upward mobility with early entry into work group while the remaining three groups are similar in size class 1 the persistently low accumulated disadvantages in human capital over this period of the life course in young adulthood a majority had not completed high school and very few were in school suggesting that most of this group had attained their maximum education adult education ranged from less than high school to high school degree or ged among parents who worked occupations were in salesservice and manual typical adult occupations were manual or salesservice class 2 was similar to class 1 in adolescence however several key differences signal upward mobility during young adulthood first 958 of respondents in this class had a high school degree in young adulthood compared to 277 in class 1 adult education levels were between a high school degree and some college which was higher than their parents but lower than other groups suggesting relatively early exit from school and entry into work second this group worked more in adolescence and young adulthood compared to all other groups this group had the highest proportion who received vocational training the modal adult occupations include salesservice and manual class 3 also had an upward trajectory the key difference with class 2 is that a majority continued schooling during young adulthood intergenerational gains are evident when comparing parents education and respondents education an upward path is also evident with occupation mothers worked primarily in salesservices and fathers in manual sectors respondents however worked in professional or managerial other professional and salesservice sectors in contrast class 4 shows downward mobility their parents had the second highest education levels of some college the majority of respondents meanwhile had a high school degree by young adulthood but by adulthood the mean education level was less than both parents in addition to early work in young adulthood there was also continued schooling in young adulthood and adulthood therefore the downward pattern may have the potential to reverse later in life but the combination of working may have made educational attainment slow for this group mothers occupation was high while fathers occupation had a wide variation the modal respondent occupation is salesservice class 5 represents accumulated advantages in human capital the majority had completed high school by young adulthood and a large proportion continued schooling in young adulthood the average adult education was between a college degree and graduate school average work hours were the lowest in young adulthood but highest by adulthood parents and respondents occupation were high at a professional or managerial level table 5 shows the relationships between demographics and human capital classes similar to economic capital the persistently low had more blacks and hispanics than the persistently high which had more whites and asians gender patterns were reversed for human capital the persistently low had more males while the persistently high had more females upward with continued schooling group comprised of more females than males the upward with early work group resembled the persistently low with more blacks and hispanics than whites but with equal gender composition the downward with early work group included more males and whites than females and nonwhites groups that continued schooling in young adulthood were characterized by younger respondents whereas the groups that entered work early were older respondents to compare the two forms of capital table 5 presents income as an indicator of economic capital across the three life stages the correspondence between economic and human capitals is most evident for the two extremes the persistently low group has the lowest incomes at all three times and the persistently high have the highest incomes except for young adulthood when they were in school income in young adulthood is highest instead among the two groups who entered the workforce early furthermore by adulthood this pattern reverses and a positive association of higher human capital and income is evident among the upward with continued school and persistently high groups thus the notion of the positive association between economic and human capitals is clearly challenged by the timedependent effects of continued school on income during this period for the transition to adulthood markers human capital tends to correspond to trends of being in school marriage and parenthood but not with living with parents the persistently low human capital had patterns of earlier adult roles relative to the persistently high human capital yet a higher proportion of persistently low lived with parents than the persistently high the upward with early work and downward with early work had patterns similar to the persistently low which signal earlier adult roles the upward with continued schooling exhibited characteristics of delayed adult roles that were comparable to the persistently high discussion while adolescence is a time of significant biological psychological and social developments the transition from adolescence to adulthood is a time of critical turning points for the accrual of social status that can have lifelong effects on ones overall health and social wellbeing social status in childhood and adolescence is often assessed via parents social status but during this transition ones own status as this study has shown may result in a continuation of the level of parental social status both advantaged and disadvantaged or discontinuity with some experiencing gains in status and others drifting downward income education and work experience begin to replace parental status sometimes abruptly and other times as a slowly evolving process understanding the status attainment process during this period is essential to identifying mechanisms for intervention in adolescence and early adulthood to deter the further accrual of social disadvantages and generation of social inequalities this study provides a more comprehensive and holistic view of the status attainment process during this transition period in the life course than existing research that relies on single indicators of social status andor treats social status as static our analysis of lifecourse social status captures the ebb and flow of social status advantages and disadvantages from adolescence through young adulthood to adulthood this analysis incorporates the intergenerational transmission of economic capital and human capital as well as the intragenerational attainment of status our results indicate that social status has stable as well as fluid patterns furthermore these trajectories are significantly associated with transition to adulthood markers our hypothesis that economic and human capital trajectories would mirror each other during this period however was only partially supported in that economic and human capital tradeoffs became clearly evident next we discuss these findings separately by stable versus fluid patterns of social status social origin and destination remain similar for some groups for both economic and human capital there are stable patterns that point to the stickiness of parents social status and are consistent with previous studies documenting a cumulative buildup of social disadvantages and advantages that start early in life and continue into adulthood and old age for the persistently advantaged groups benefits from the intergenerational transmission of parents status enabled them to stay on top of the status hierarchy as a result social inequalities between the most disadvantaged and advantaged grew wider by adulthood as evidenced by differences in subsequent income and education levels however these stable patterns were present only at the top and bottom of the social ladder this may indicate that stability is less common among the middle class or it may be an artifact of the data or modeling procedures it is possible for example that a larger sample would yield a greater number of latent classes and that the additional latent classes would reveal stickiness in the middle class too alternately stability in the middle class may be embedded in the persistently advantaged group although the mean level of income in this group is well above the sample average the range is relatively wide providing some support to this interpretation however our construct of social status accounts for different trajectories of multiple dimensions in addition to income and thus stability may represent other aspects of social status such as experiences of economic hardship wealth or occupations nevertheless the stickiness of the most disadvantaged groups speaks to the need for social policy directed at reducing poverty and inequality early in the life course bifurcation of the transition to adult social roles is evident between these two stable patterns of social status compared to the persistently advantaged those who are persistently disadvantaged in economic or human capital were more likely to be out of school married and have children by young adulthood marital patterns changed by adulthood however when the persistently advantaged group was more likely to be married but with fewer children suggesting that they are delaying marriage and parenthood and investing time in young adulthood to accrue their higher social status in adulthood in contrast social mobility patterns show that social destinations can differ from origins with respect to economic capital the upwardly mobile provide an initially optimistic outlook of how material resources can grow with limited intergenerational status contribution however their social status may not remain as high later in life when some other groups have completed higher education and the transition to adulthood nevertheless this group is faring better than their parents thus upward economic mobility may be evident between generations but may be less so when comparing across social status groups within a generation the economically downward in contrast have the potential to reverse course because this group has the highest proportion still in school in adulthood therefore this groups economic status may yet come to resemble that of their parents status the potential for these groups to change course signals a need for research that spans from adolescence to even later in adulthood within the human capital domain upward mobility is evident through two pathways leaving school early to work and delaying work to continue schooling although both of these groups have higher human capital levels than their parents the benefits of the second trajectory of continuing school are evident by adulthood those who entered the workforce early received immediate economic gains in young adulthood those who continued school however attained educational occupational and income levels similar to levels in the persistently high human capital group an analogous pattern is also evident with the adult role trajectories of marriage and parenthood those who entered the work force early resembled in contrast the persistently disadvantaged in taking up these roles the downward with early entry into work in contrast did not accrue benefits from their parents high education levels and while their relative economic gains were noticeable in young adulthood their status dropped by adulthood although some members of this group continued school and invested in vocational training in young adulthood this juggling of work and school may have delayed their human capital attainment and transition to adulthood this combination appears to be a downward trajectory but this group still has the potential to reap benefits from their education in the future inequalities by social status patterns are evident by gender and raceethnicity females make up a larger proportion of the most disadvantaged economic capital group however within the human capital domain females have a larger proportion in the upward with continued schooling and the persistently high groups these patterns highlight the potential social status benefits via human capital for females but less so in the economic capital domain alternatively human capital could be a leading indicator for future economic capital which may not have been captured by the data to date blacks and hispanics are more likely to be in the most economically disadvantaged and the persistently low human capital groups yet they are also more likely to be in the economically upward group and upward with early entry into work group although blacks and hispanics tend to possess low social status regardless of domain on average it is important to look at ways to maximize the upward mobility pathways that can elevate the status of blacks and hispanics during the transition to adulthood these findings demonstrate the importance of looking at social status through a lifecourse perspective to capture stability and change over time because they show that status attainment is a dynamic process that ebbs and flows for some while others follow a steady cause furthermore although a unidimensional approach to conceptualizing social status is parsimonious these results highlight several advantages of applying a multidimensional approach first the trajectories of economic and human capitals align with each other but do not necessarily match and therefore these dimensions should be considered both jointly and separately initial upward economic trajectories may come at the longterm cost of human capital accumulation while longterm upward human capital investments may come at the initial cost of economic accumulation more simply put the meaning of economic trajectories may differ from human capital trajectories during this sensitive period in the life course second snapshots at a single point in time have very little meaning during the transition to adulthood and even unidimensional trend analyses of single indicators of social status can be misleading in separate analyses using indicators at one time point earlier onset of adulthood is common among those with low adolescent income and low adult income yet our results show that even though the economically upward is similar to the persistently advantaged by adulthood this group exhibits earlier adult roles similar to the persistently disadvantaged thus early adult onset is not necessarily associated with low social status and anomalies exist in the intertwining pathways of status attainment and entry into adult social roles indicating that the social bifurcation of the transition to adulthood is not certain third by examining nontraditional measures of economic capital and human capital a fuller picture of status attainment and targets for potential intervention during the transition to adulthood are more evident specifically while educational attainment and occupation are traditional measures early exit from school and early entry into work are key turning points for human capital trajectories programs to reduce educational inequalities should focus on providing opportunities for delaying school exits finally the status attainment process is for most participants in this study incomplete and the future remains undetermined there are several limitations to this study these findings are only generalizable to us adolescents enrolled in school during the 199495 academic year and therefore omit the experiences of those who are perhaps most at risk of persistently low or downward mobility those who leave school early the sample includes only whites blacks latinos and asians neglecting the experiences of other racialethnic groups whose status attainment is likely to be affected by their minority group status lca involves a degree of subjectivity in the interpretation of latent classes and some class misclassification error such that some groups that exist in the population are probably not fully captured in these classes furthermore respondents were between the ages of 25 and 31 at wave 4 although previous studies of status attainment assess final adult status between the ages of 25 and 30 our findings should be interpreted with caution given that the process of status attainment is not complete for most respondents given the elongation of the transition to adulthood future research should apply these kinds of analytical methods to other longitudinal datasets that capture the transition to adulthood period into midtolate adulthood to expand these findings another limitation is the inability to consider larger societal influences on status attainment the life course theorys principle of time and place emphasizes the importance of historical context on the life course of individuals and birth cohorts for the add health study cohort adolescence occurred during economic growth in the 1990s it is not possible to assess the impact of these economic forces however given that the study was conducted with a single cohort during one span of time future research that compares this process across different cohorts andor different historical times may illuminate these historical contexts one of the studys key strengths is the use of longitudinal data to identify social status patterns over time although this study is limited to a schoolbased sample and overlooks individuals who were already out of school by wave 1 as just mentioned there was much heterogeneity in social status groups that reflected economic and human capital levels across the social ladder at the beginning and throughout the study second this study used a personoriented framework to develop lifecourse social status constructs for economic and human capitals through this conceptualization this studys findings provide a nuanced understanding of social status during the transition from adolescence to adulthood previous studies are often limited to crosssectional data or lack the richness of multiple social status measures conclusions this studys findings suggest key implications for research practice and policy first young adult research that incorporates social status should take a more comprehensive approach that accounts for intergenerational timevarying and multidimensional aspects of social status second the transition to adulthood and status attainment are deeply intertwined which makes it difficult to tease these processes apart therefore the timing of these key events should be considered together to highlight patterns of social inequalities for example the effects of leaving school early and starting work can lead to lower human capital and later economic capital gains in addition becoming a parent early in adulthood is associated with less social status development finally the process of reproducing social inequality is being played out in the lives of these young people as they make decisions and respond to external forces that set them on pathways of continuing to accumulate the disadvantage of their parents lives or building advantage on advantage or instead transform their destinations to bear little resemblance to their origins overcoming disadvantage or letting privilege slip through their fingers with a better understanding of the timing of key events that affect the different social status dimensions we can develop appropriate interventions that function as safety nets during the transition to adulthood these interventions can focus on elements of social status development or transition to adult roles furthermore public policies that account for these variations in status attainment during the transition to adulthood can serve to buffer against times of economic uncertainty create stronger links between school and work and prevent buildup of disadvantages in conclusion the transition to adulthood is a period when social status may evolve rapidly across each economic capital and human capital domain these changes indicate that social status trajectories are neither linear nor fixed except perhaps at the extremes accurately capturing the process of accruing capital during this critical transition period of the life course is essential for the development of optimal interventions and public policies

the transition from adolescence to adulthood is a critical time for status attainment with income education work experience and independence from parents accruing at varying speeds and intensities this study takes an intergenerational lifecourse perspective that incorporates parents and ones own social status to examine the status attainment process from adolescence into adulthood in the domains of economic capital eg income and human capital eg education occupation survey data from three waves of the national longitudinal study of adolescent health analytic n8977 are analyzed using latent class analysis to capture the ebb and flow of social status advantages and disadvantages from adolescence wave 1 through young adulthood wave 3 into adulthood wave 4 the analytic sample is composed of 503 females and 702 whites 153 blacks 110 hispanics and 35 asians ages 12 to 18 at wave 1 and 25 to 31 at wave 4 four latent classes are found for economic capital and five for human capital the importance of parents social status is demonstrated by the presence of large groups with persistently low and persistently high social status over time in both domains the capacity of individuals to determine their own status however is shown by equally large groups with upward and downward mobility in both domains these findings demonstrate the dynamic nature of social status during this critical developmental period

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introduction south africa is home to the highest number of plwh 1 and kwazulunatal province has the highest hiv prevalence nationally 2 south africas hiv testing and care cascade stands at 927064 3 highlighting the great progress made in terms of people knowing their hiv status but more effort is still needed to reach the united nations programme on hivaids 959595 targets by 2025 4 individuals younger than 35 and men account for most of the people untested for hiv in kzn inconvenient clinic operating times stigma and preference for using traditional medicine are some of the barriers which prevent men from accessing facilitybased hiv testing services alternative strategies to facilitybased hts are needed to reach these hardtoreach populations hiv selftesting using a simple oralfluid or bloodbased selftest at a time and place convenient to the person testing is a promising alternative strategy that addresses many barriers associated with facilitybased hts and has the potential to increase testing among persons who do not usually go to clinics different hivst kit distribution strategies such as distributing through peer adolescent networks and distributing to female sex workers can be used to reach vulnerable populations who may experience barriers to accessing facilitybased testing secondary distribution of hivst where an hivst kit is given to an individual for distribution to a third party has been shown to reach male partners of women attending health facilities and can facilitate couplestesting secondary hivst kit distribution by peers in fishing communities was successful at finding untested men in one study in uganda in subsaharan africa secondary kit distribution studies have primarily engaged women to distribute hivst to partners and contacts little is known about secondary hivst kit distribution using index distributors of both male and female plwh as distributors in south africa we aimed to assess the willingness of both male and female plwh to distribute hivst kits to social networks including sexual partners and to determine kit usage test positivity and linkage outcomes from this distribution approach methods study design this was an observational cohort study nested within the delivery optimization of antiretroviral therapy trial of differentiated art delivery in kzn south africa between july and november 2018 all do art participants attending followup visits in the periurban district of umgungundlovu and the rural district of umkhanyakude were offered a choice of either oral swab or bloodbased hivst kits to give to their adult contacts hivst kit distributors were informed that contacts could be a partner relative friend or neighbour we did not restrict the gender of hivst kits recipients hivst kit distributors were allowed to take up to 4 kits when receiving the hivst kits hivst kit distributors were given a brief instruction on how to use and demonstrate use of the kits to kit recipients they were asked who they intended to give the kits to and they were also given links to instructional videos which they could show or watch on their phones the hivst kits had instructions in the local language to call the study phone number when the kit recipient had completed the test and was ready to give a result following a similar approach used in the hivst substudy an airtime voucher valued at 2 usd was provided to kit recipients at the time they reported results as an incentive to provide hivst results the hivst kit distributors did not do any communication of results to study staff study procedures the hivst kit distributors completed a questionnaire while being issued hivst kits the questionnaire included topics such as their marital status number of sexual partners highest educational level completed occupation partner hiv status intended kit recipients and number of kits taken kit recipients who completed the test and contacted the study team were taken through a telephonic questionnaire about demographic and clinical details the kit recipients who called back with results were given the appropriate counselling dependent on the result those who tested negative received counselling on hiv prevention and those tested positive were counselled to go to the nearest clinic for confirmatory testing with two rapid hiv tests according to the national algorithm and linkage to art or come to the do art study for confirmatory testing and enrolment for linkage to art a second phone outreach was conducted to kit recipients who reported a positive hivst result to assess linkage to care study staff confirmed with clinic art registries all participants who selfreported linkage to care study staff also conducted an art registry search of department of health clinics to identify any latelinking persons after the reporting period concluded statistical analysis univariate descriptive analyses were conducted and presented in percentages key demographic and clinical characteristics of the kit distributors were described using percentages the main outcome of interest was the return rate or proportion of distributed kits whose results were reported to the study we then characterized the remainder of the hivst cascade we determined the proportion of returned hivst results that were positive and the proportion of persons with reactive hivst results who subsequently linked to care for confirmatory testing and initiation of art ethics the hivst kit distributors provided written informed consent to participate in the do art study and a separate consent to receive and distribute hivst kits informed consent was obtained from secondary kit recipients over the phone once they called to give results after using the hivst kit consent to use the test was implied if kit recipients contacted the study to report their results this study received ethical approval from the human sciences research council the university of kwazulunatal and the university of washingtons ethical committees results a total of 63 hivst kit distributors took 218 hivst kits to distribute to secondary contacts with a median of 4 kits taken per participant the hivst kit distributors dispersing kits were 48 male and 52 female the hivst kit distributors median age was 34 years fiftyfive percent indicated they were in a relationship and 84 indicated having 1 sexual partner seventy five percent of those who took kits for distribution were unemployed 89 reported an educational level at secondary or above seventy six percent indicated not knowing their partners hiv status and 46 kits were reported to be intended to be given to a friend 13 kits were intended to given to a sexual partner a total of 147218 intended kit recipients contacted the study after using the kits recipients were 65 males and 82 females eightyfive recipients reported having previously tested for hiv prior to using the hivst kit and 143147 reported their hivst results four participants had missing data and therefore were recorded as not reporting their results most of the hivst results reported were negative at 92 from the 11 recipients who reported positive hivst results only 1 reported being linked to care discussion in this evaluation of secondary distribution of hivst kits by male and female plwh we found that secondary kit distribution achieved a return rate of 143 of 218 kits used with results reported the outcome of 75 kits remained unknown from results reported 62147 indicated being first time testers highlighting the potential secondary hivt kit distribution has to find firsttime testers even though 11 kit recipients reported to have tested positive only 1 linked to care leaving 10 with unknown linkage this highlights the fact that hivst can get people tested but more support is needed to fully link them to care in finding firsttime testers our results are similar to findings by choko et al who reported that secondary kit distribution using fishermen peers reached 2389 men who had not previously tested for hiv in uganda finding firsttime testers will be an important step to overcome if the unaids first 95 testing cascade will be achieved in kzn by 2025 secondary kit kits were intended to be distributed to adults a proportion of the hivst kit distributors indicated wanting to give the kits to their adolescentadult children distribution could be used an alternative strategy to find those not previously tested one challenge in evaluating secondary kit distribution is the reliance on testers to selfreport their results thus the number of hivst results we received is an underestimate of the number of tests actually used in their study of secondary kit distribution choko et al found that 8794 participants recruited through fishermen peers in uganda reported their hivst results this reported percentage is much higher than the 66 reporting we found but a major difference between the two studies is that the peers who distributed the kits in uganda had to bring back the kits irrespective if they had been used in contrast hensen et al reported that 460825 kit recipients confirmed to have used the kits after secondary distribution by community hiv care providers in 4 communities within zambia in this study kit recipients also had to return the kits to the chips whether used or not across all studies more kits were used and had results reported compared to unusedunknown kits regardless of the reporting approach we recommend that hivst through secondary kit distribution is sufficiently high yield that it should be scaled up even with the understanding that not all kits may be used or lead to immediate engagement in care from the hivst kit distributors who dispersed kits 48 indicated not knowing their partners hiv status yet only 13 kits were intended to distributed to a sexual partner these results contrast with findings from masters et al who reported that secondary kit distribution by women seeking antenatal and postpartum care in kenya promoted partner testing potential reasons for partners not wanting to distribute kits to partners could be that positive results can invite stigma abandonment discrimination violence and emotional distress secondary distribution of hivst kits by plwh to their sexual partners may result in disclosure of the distributors hiv status additional elements could be incorporated into a program of hivst distribution to social contacts in order to minimize social harms associated with status disclosure and promote partner kit distribution thirumurthy et al described an approach where secondary kit distributors were taught to use discretion when introducing selftests to sexual partners by assessing likely reactions of their partner as well as the risk of intimate partner violence scaleup of secondary kit distribution in the region should explore using these strategies an overwhelming majority of those who reported testing positive did not link to care future kit distribution programs should strengthen follow up and linkage to encourage those who test positive to easily link to care future research should explore reasons why people who reported to test positive through secondary hivst kit distribution do not link to care this study had several limitations including that we had no way to contact the kit recipients we could not confirm if the hivst kit distributors intended kit recipients were the ones who received the kits also even though two thirds of the participants responded with their results this percentage is lower than the 80 responder percentage reported by a concurrent study providing primary distribution of hivst kits to recipients in the same areas some kits may have been discarded before they were distributed or recipients may not have used their kits we were unable to ascertain results of kits that were used or characteristics of the person who used the kit unless the recipient elected to contact the study finally selfreported hivst results and linkage data are subject to some bias if kit recipients already knew their status but had not disclosed to the distributor this could have led to them accepting a test but not using it or not reporting their results the strength of the study is that it was done in an operationally friendly way using an existing structure of a communitybased study so it didnt have to create an entirely new infrastructure the limited infrastructure requirements of this project suggest that results would be similar if translated into a public health setting for example implementing a secondary distribution programme in existing hiv treatment sites conclusions we found that secondary kit distribution using both male and female plwh as hivst kit distributors can engage social contacts into hiv testing however low subsequent linkage to care among persons testing positive indicates further support with linkage is needed this strategy can extend testing from facilitybased into the community and reach firsttime testers and further efforts to improve linkage should be explored for persons accessing hivst data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement this study received ethical approval from the human sciences research council the university of kwazulunatal and the university of washingtons ethical committees the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

background to reach 95 of persons living with hiv plwh knowing their hiv status alternative testing approaches such as hiv selftesting hivst and secondary hivst kit distribution are needed we investigated if secondary hivst kit distribution from male and female plwh in south africa would successfully lead to their contacts testing for hiv and linking to care if positive methods male and female plwh participating in an hiv treatment trial between july and november 2018 in kwazulunatal south africa were offered participation as hivst kit distributors in a pilot of secondary distribution of hivst kits to give to sexual partners and social networks univariate descriptive statistics were used to describe the characteristics of volunteer distributors proportion of hivst recipients who reported their results and linkage to care among those who tested positive using hivst were assessed results sixtythree participant kit distributors accepted kits to disperse to contacts of whom 52 were female median age was 34 years iqr 26425 84 reported 1 sexual partner and 76 did not know their partners hiv status hivst kit distributors took 218 kits with 13218 6 of kits reported to be intended to be given to a sexual partner a total of 143 hivst recipients reported their hivst results 92 reported their results were negative 11 recipients reported positive results and 1 hivstpositive recipient was linked to hiv caresecondary distribution of hivst to social networks and sexual partners from south african plwh is feasible with two thirds of contacts reporting use of the hivst kits additional support is necessary to facilitate linkage to care

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introduction fitness applications are gaining traction worldwide due to the global problem of physical inactivity and the need to become fit andor stay in shape by exercising regularly these applications are being used in different contexts to motivate exercise behavior change they are also being used in different modes to encourage exercise behavior change however for these applications to be more effective there is a need for designers to tailor them to the target audience research 1 2 3 shows that understanding potential users persuasion profiles will help designers tailor persuasive health applications to future users to make them more effective persuasion profile 4 is an ordered list of persuasive strategies or features to which potential users of a persuasive health application are likely to be susceptible moreover research shows that persuasive applications can be tailored based on demographic variables in particular gender 56 and culture 78 have been found to be useful demographic factors based on which persuasive health applications can be tailored to different user groups in a given population groupbased tailoring has become important given that in certain situations designers may not have the required resources to implement finegrain tailoring at the personal level which entails tailoring to the individual based on hisher personal dynamic user model and profile in such a case while individualbased tailoring could be easily implemented by big players given the huge human and algorithmic resources at their disposal for small players with limited resources tailoring at the group level may be necessary to reduce the cost of application implementation and deployment time to market however in the health domain there are limited crosscultural studies aimed at investigating how different cultural groups may respond to different persuasive strategies employed in motivating exercise behavior change specifically there are limited comparative studies involving participants from western and african cultures most persuasive health applications are designed and targeted at users in western cultures as such most persuasive technology studies have been focused on western societies in north america and europe 9 however most persuasive health applications are used in nonwestern societies in asia and africa as well while the two major target countries in north america are individualist cultures most target countries in asia and africa are collectivist cultures individualist cultures are societies in which people are independent and selfmotivated in their pursuits of lifes goals while collectivist cultures are societies in which people are interdependent and socially motivated in the pursuit of lifes goals research 7 shows that this difference in the two main types of cultures influences the way people in the respective cultures perceive and use humancomputer interaction applications in general and persuasive technologies in particular hence persuasive strategies that are effective in europenorth america may not be effective in asia andor africa for this reason there have been several calls on the need to tailor persuasive applications to different cultures to make them more effective however in the fitness domain there is limited crosscultural research on the differences between users from individualist and collectivist cultures in terms of their susceptibility to persuasive strategies commonly employed in mobile health applications according to 11 examining how culture influences persuasion has not yet been given much attention by persuasive technology researchers designers can leverage the empirical evidence on cultural differences to tailor persuasive health applications to users in the respective cultures so that they can be more effective in motivating exercise behavior change as a result we conducted an empirical study to investigate how subjects from canadaunited states and nigeria differ with respect to their susceptibility to six commonly employed persuasive strategies in fitness applications on the market they include goalsettingselfmonitoring reward competition cooperation social learning and social comparison 1213 these strategies were illustrated on storyboards as persuasive features and participants from both cultures were requested to rate them in terms of perceived persuasiveness secondly participants were asked to rank all six persuasive strategies from the one that would motivate them the most to the one that would motivate them the least the ranking measure was employed in addition to the rating measure to offset the different levels of criticality that may exist in the evaluation of humancomputer interaction artifacts by subjects from both cultures the results of our analysis revealed that based on the ratings of the storyboards participants from the collectivist culture are likely to be susceptible to all six persuasive features however participants from individualist culture are only likely to be susceptible to the personal persuasive features the only social strategy individualist participants are likely to be susceptible to is competition our betweengroup analysis shows that based on the rating of the six storyboards the collectivist group is more likely to be susceptible to all six persuasive features than the individualist group however based on the ranking of the six persuasive strategieswhich is independent of the different levels of criticality that may exist in the evaluation of hci artifacts by both culturesour results show that the individualist group is more likely to be susceptible to goalsettingselfmonitoring and reward than the collectivist group on the other hand our results revealed that the collectivist group is more likely to be susceptible to cooperation and social learning than the individualist group thus we conclude that overall personal persuasive strategies are more likely to be effective in individualist cultures than in collectivist cultures while social persuasive strategies are more likely to be effective in collectivist cultures than in individualist cultures moreover we conclude that both personal and social persuasive strategies are likely to be effective in collectivist cultures such as nigeria however only competition in addition to the personal strategies are likely to be effective in individualist cultures such as canadaunited states thus we recommend that while personal and social persuasive strategies can be employed to motivate behavior change in collectivist cultures personal persuasive strategies should be given priority in individualist cultures the rest of the paper is organized as follows section 2 provides a background on persuasive strategiesfeatures section 3 dwells on the related work section 4 describes the study design and method section 5 focuses on the result section 6 presents the discussion while section 7 concludes the paper background this section provides a brief overview of the cultural framework used in this study as an analytic framework of comparative analysis and the six persuasive features commonly employed in persuasive health applications culture culture is defined as the collective programming of the mind 15 which results in a common way of doing things by a group of people in the larger society in hci research 16 shows that culture can influence the way people perceive and interact with information systems and artifacts such as websites 8 health applications 10 etc hofstedes cultural framework turns out to be one of the most widely used frameworks for hci research individualism is a worldview that puts the i and me before the we and us hence in the individualist culture people are more concerned about the pursuit of personal goals than collective goals thus they become very independent selfreliant and selfmotivated in the pursuit and achievement of their personal goals and aspirations in contrast collectivism is a worldview that puts the we and us before the i and me hence in the collectivist culture people are more concerned about the pursuit of social goals than personal goals thus they become very interdependent and socially driven in the achievement of the goals and aspirations of the ingroups to which they belong in this paper our comparative analysis was conducted using this cultural framework of individualism vs collectivism using canadaunited states and nigeria respectively as a case study persuasive features persuasive features are motivational affordances with which persuasive applications are equipped to promote user adoption and behavior change 17 table 1 shows the definition of all six persuasive features of interest which are commonly employed in persuasive health applications on the market to motivate behavior change 12 they are drawn from the persuasive system design model put forward by oinaskukkonen and harjumaa 18 table 1 commonly employed persuasive features in persuasive applications and their definitions 12131920 the indicates that in our storyboards we implemented goalsetting and selfmonitoring as a single feature as we considered both as complementary features and discussed them as such in the paper feature definition goalsetting goalsetting is a persuasive feature that allows users to set goals prior to tracking their performance of the target behavior and progress over time selfmonitoring selfmonitoring is a persuasive feature that allows users to keep track of their performance of the target behavior and progress over time reward reward is a persuasive feature that allows incentives such as points badges levels etc to be awarded to users whenever they achieve their goals or reach a certain milestone cooperation cooperation is a persuasive feature that allows two or more users to work together as a team to reach their collective goal social learning social learning is a persuasive feature that allows users in a collaborative setting to observe the performance of the behavior progress and achievements of one another social comparison social comparison is a persuasive feature that allows users in a collaborative setting to view and compare their performance progress and achievements with those of others competition competition is a persuasive feature that allows users to compete against one another towards achieving a mutually exclusive reward related work in the persuasive technology domain a substantial amount of studies has been conducted to uncover user susceptibilities to persuasive strategies with a view to tailoring persuasive applications to different target populations such studies usually look at gender age and culture as potential demographic variables based on which persuasive applications can be tailored to users to make them more effective in this review we focused on the relevant studies kaptein et al 21 conducted a study to examine the relationship between users susceptibility to persuasive cues and compliance to persuasive requests they found that the susceptibility to persuasive cues could enhance users compliance to persuasive requests specifically they found that the more susceptible users are to persuasive cues the more likely they will comply with persuasive requests such as provision of email address however the authors did not investigate the influence of culture on users compliance to persuasive requests neither did they conduct the study in the physical activity domain orji et al 2223 examined the effect of culture gender and age on users susceptibility to the six cialdinis principles of persuasion 24 using subjects from north america and asia as a case study the cialdinis 24 six principles include commitment reciprocity authority liking consensus and scarcity orji et al 2223 found that irrespective of all three demographic factors users are most likely to be responsive to the commitment principle which is usually mapped to goalsetting in the persuasive technology domain 25 however in the first study orji et al 23 found that adults are more likely to be susceptible to commitment than younger adults while younger adults are more likely to be susceptible to scarcity than adults 23 in the same study the authors found that females are more likely to be susceptible to commitment reciprocity and consensus than males 23 in the second study orji 22 found that users from collectivist culture are more likely to be susceptible to authority reciprocity liking and consensus than users from individualist cultures however the authors did not investigate most of the persuasive strategies our current study is concerned with such as reward competition social learning cooperation etc as a followup to orji et als 2223 studies oyibo et al 2526 carried out similar studies to examine the effect of culture 25 and gender 26 on users susceptibility to all six cialdinis principles of persuasion using subjects from canada and nigeria as a case study the authors replicated orji et als 2223 findings specifically they found that regardless of culture and gender participants are most 25 likely to be susceptible to the commitment principle regarding the effect of culture oyibo et al 25 found that individualists are more likely to be susceptible to reciprocity liking and consensus than collectivist while collectivists are more likely to be susceptible to authority than individualists all of these findings which were based on the rating measure were replicated using the ranking measure except that regarding reciprocity while oyibo et als 25 study among collectivists and individualists replicated orjis 22 finding that collectivists are more likely to be susceptible to authority than individualists it did not regarding reciprocity and liking orji 22 found that collectivists are more likely to be susceptible to reciprocity and liking than individualists however oyibo et al 25 found that individualists are more likely to be susceptible to reciprocity and liking than collectivists this finding suggests that collectivists from different continents and countries could differ in their susceptibility to cialdinis principles of persuasion therefore more studies need to be done in this research area to investigate how collectivists in different continents and countries differ in their responsiveness to cialdinis principles of persuasion in particular and persuasive strategies in general however oyibo et als 25 study just like orji et als 2223 studies did not investigate persuasive strategies such as reward competition social learning cooperation etc which our present study addressed oyibo et als 25 study was also not carried out in the specific context of physical activity as our current study oyibo et al 27 investigated the moderating effect of culture on the influence of gender and age on socialinfluence strategies using nigeria and canada as a case study they found that males are more likely to be susceptible to reward and competition than females in the collectivist culture but no difference between both genders in the individualist culture they also found that younger people are more likely to be susceptible to social comparison and social learning than older people in the collectivist culture but no difference between both age groups in the individualist culture moreover they found that younger people are more likely to be susceptible to competition than older people in both cultures however the authors did not investigate how both types of cultures differ directly with respect to their susceptibility to the socialinfluence strategies they investigated in addition their study was not carried out in the physical activity domain it was done in a nondomainspecific context finally in our earlier studies we investigated the susceptibility of collectivists 28 and individualists 17 to all six persuasive features we examined in this paper in the first study 28 we found that based on the rating measure collectivists are likely to be susceptible to all six features in particular we found that they are most likely to be susceptible to goalsettingselfmonitoring and reward and least likely to be susceptible to social comparison and social learning however based on the ranking measure we found that they are more likely to be susceptible to goalsettingselfmonitoring than the other persuasive features in the second study 17 we found that based on the rating measure individualists are likely to be susceptible to the personal features and competition and unlikely to be susceptible to cooperation social learning and social comparison these findings were replicated using the ranking measure however in both studies we did not investigate the moderating effect of culture our current study aimed to bridge this gap by comparing how users in collectivist and individualist cultures differ in their susceptibility to the six persuasive features of interest which are commonly employed in persuasive applications aimed at motivating behavior change method this section focuses on the research objective measurement instruments and demographics of the participants that took part in the study research objective the aim of our study is to investigate using storyboards the differences between the individualist culture and the collectivist culture with respect to their persuasion profiles 4 using canadaunited states and nigeria respectively as a case study the persuasion profiles are based on six commonly employed persuasive features illustrated on storyboards these persuasive features are drawn from the psd model 18 for example figure 1 shows the storyboard for social learning in this storyboard the user is able to view the goal of his friend kim who sets out to achieve a small goal of 4000 calories for the day once kim achieves his goal the user receives a notification informing him that kim has achieved his goal storyboards such as this have been successfully used in prior studies 12 to uncover useful persuasive system design information from potential users using storyboards such as these the main research question this study aimed to address is presented as follows what are the differences between the persuasion profiles of users in collectivist and individualist cultures with respect to their susceptibilities to goalsettingselfmonitoring reward competition cooperation social learning and social comparison information 2019 10 x for peer review 6 of 21 method this section focuses on the research objective measurement instruments and demographics of the participants that took part in the study research objective the aim of our study is to investigate using storyboards the differences between the individualist culture and the collectivist culture with respect to their persuasion profiles 4 using canadaunited states and nigeria respectively as a case study the persuasion profiles are based on six commonly employed persuasive features illustrated on storyboards these persuasive features are drawn from the psd model 18 for example figure 1 shows the storyboard for social learning in this storyboard the user is able to view the goal of his friend kim who sets out to achieve a small goal of 4000 calories for the day once kim achieves his goal the user receives a notification informing him that kim has achieved his goal storyboards such as this have been successfully used in prior studies 12 to uncover useful persuasive system design information from potential users using storyboards such as these the main research question this study aimed to address is presented as follows what are the differences between the persuasion profiles of users in collectivist and individualist cultures with respect to their susceptibilities to goalsettingselfmonitoring reward competition cooperation social learning and social comparison research design and measurement instruments the research design was based on the rating and ranking of the six persuasive features of interest in an online survey six storyboards illustrating the six persuasive features were administered to participants from both cultures this was followed by a questionnaire on the perceived persuasiveness of the features illustrated on the storyboards for participants to answer and a list of the six persuasive features for participants to rank in terms of perceived persuasiveness to contextualize the study and set the tone for the participants response to the questionnaire we presented them with a description of a hypothetical fitness application we called the homex app the description read as follows imagine you want to improve your personal health and fitness level given the challenges associated with going to the gym regularly the homex app has been created say by health promoters in your neighborhood to support your physical activity research design and measurement instruments the research design was based on the rating and ranking of the six persuasive features of interest in an online survey six storyboards illustrating the six persuasive features were administered to participants from both cultures this was followed by a questionnaire on the perceived persuasiveness of the features illustrated on the storyboards for participants to answer and a list of the six persuasive features for participants to rank in terms of perceived persuasiveness to contextualize the study and set the tone for the participants response to the questionnaire we presented them with a description of a hypothetical fitness application we called the homex app the description read as follows imagine you want to improve your personal health and fitness level given the challenges associated with going to the gym regularly the homex app has been created say by health promoters in your neighborhood to support your physical activity rating measure regarding the rating measure the following question was posed to participants after each of the storyboards had been shown to them imagine that you are using the homex app presented in the storyboard above to track your physical activity to what extent do you agree with the following statements 1 this feature of the app would influence me 2 this feature of the app would be convincing 3 this feature of the app would be personally relevant to me 4 this feature of the app would make me reconsider my physical activity the above scaleranging from strongly disagree to strongly agree has been used in prior studies such as 2 before participants began answering the above questions they were asked to briefly study the persuasive feature being illustrated on each storyboard and choose the correct one from a list of options each option comprised the name and definition of each persuasive feature for example goalsettingselfmonitoring was defined as an application that allows a user to set a goal and track hisher own performance or status it provides information on both past and current performance this was intentionally done to increase the reliability of participants responses and our findings as such in the process of data cleaning participants responses to wrongly identified persuasive features were treated as missing data points and filled in with the appropriate average scores ranking measure in addition to rating the six persuasive features illustrated on the storyboards participants were asked to rank them as well the persuasive features were presented to participants in a list format all of which were randomized for each participant we added the ranking measure to account for the different levels of criticality that may exist between the individualist and collectivist cultures when evaluating hci artifacts for example oyibo et al 14 found that canadians are more likely to be critical of mobile website design than nigerians to account for this cultural difference we asked participants to rank the six persuasive features from the one that would be most helpful to the one that would be least helpful in achieving their goals the question we asked them is please rank these features starting with the one you think will help you achieve your exercise goals the most to the least this question will help us to tease out which set of persuasive features to which one culture is more likely to be susceptible than the other we might not be able to tease out this information based on the rating measure alone if the rating of the persuasive features illustrated on the storyboards was influenced by the userinterface and information design for example one culture overall may rate their susceptibility to the persuasive features illustrated on the storyboards higher than the other by taking into consideration their judgment of the ui and content design results this section covered the results of our data analysis including the reliability analysis for the six persuasive constructs their average ratings and rankings and analysis of variance measurement instrument reliability analysis prior to conducting data analyses we carried out reliability tests on the six persuasive strategies to ensure they were reliably measured by their respective scales given that our data set was not normally distributed like most questionnaire data we based the reliability tests on the mcdonalds omega metric rather than the cronbachs alpha metric which is meant for normally distributed data 31 specifically we used the cireliability function in the mbess library in r for the reliability test for each construct the results of the analyses showed that all of the constructs met the reliability requirement 32 overall average rating and ranking of persuasive features to determine the overall persuasion profile we calculated the mean rating and ranking of each persuasive feature as shown in figure 2 if we were to use the meanrating values above the neutral value of 4 as an indication of susceptibility likelihood then overall based on the rating metric participants were more likely to be susceptible to goalsettingselfmonitoring reward and competition and less likely to be susceptible to cooperation social comparison and social learning similarly if we were to use the meanranking values above the overall average value of 35 as an indication of susceptibility likelihood then overall based on the ranking metric participants were more likely to be susceptible to goalsettingselfmonitoring and reward and less likely to be susceptible to social comparison cooperation social learning and competition overall the rating and ranking profiles seemed to correspond for example based on the rating and ranking metrics goalsettingselfmonitoring turned out to be the most persuasive feature followed by reward and competition this is an indication that the determination of the persuasion profile of a given population could be based on ranking of persuasive features instead of rating to determine the overall persuasion profile we calculated the mean rating and ranking of each persuasive feature as shown in figure 2 if we were to use the meanrating values above the neutral value of 4 as an indication of susceptibility likelihood then overall based on the rating metric participants were more likely to be susceptible to goalsettingselfmonitoring reward and competition and less likely to be susceptible to cooperation social comparison and social learning similarly if we were to use the meanranking values above the overall average value of 35 as an indication of susceptibility likelihood then overall based on the ranking metric participants were more likely to be susceptible to goalsettingselfmonitoring and reward and less likely to be susceptible to social comparison cooperation social learning and competition overall the rating and ranking profiles seemed to correspond for example based on the rating and ranking metrics goalsettingselfmonitoring turned out to be the most persuasive feature followed by reward and competition this is an indication that the determination of the persuasion profile of a given population could be based on ranking of persuasive features instead of rating culturebased average rating and ranking of persuasive features figure 3 shows the culturespecific mean ratings and rankings respectively of the six persuasive features the barcharts reveal that for the collectivist group they are likely to be susceptible to all six persuasive features and to goalsettingselfmonitoring cooperation social learning and reward on the other hand for the individualist group the barcharts show that they are likely to be susceptible to goalsettingselfmonitoring reward and competition comparatively based on the rating measure the barcharts reveal that the collectivist group is more likely to be susceptible to the six persuasive features than the individualist group however based on the ranking measure the barcharts reveal that the individualist group is more likely to be susceptible to goalsettingselfmonitoring and reward than the collectivist group while the collectivist group is more likely to be susceptible to cooperation and social learning than the individualist group that said our twoway anova will determine whether for each measure and persuasive feature the numerical difference in the mean scores of the two cultural groups are statistically significant at p 005 culturebased average rating and ranking of persuasive features figure 3 shows the culturespecific mean ratings and rankings respectively of the six persuasive features the barcharts reveal that for the collectivist group they are likely to be susceptible to all six persuasive features and to goalsettingselfmonitoring cooperation social learning and reward on the other hand for the individualist group the barcharts show that they are likely to be susceptible to goalsettingselfmonitoring reward and competition comparatively based on the rating measure the barcharts reveal that the collectivist group is more likely to be susceptible to the six persuasive features than the individualist group however based on the ranking measure the barcharts reveal that the individualist group is more likely to be susceptible to goalsettingselfmonitoring and reward than the collectivist group while the collectivist group is more likely to be susceptible to cooperation and social learning than the individualist group that said our twoway anova will determine whether for each measure and persuasive feature the numerical difference in the mean scores of the two cultural groups are statistically significant at p 005 twoway analysis of variance based on culture and persuasive feature given the nonnormality of our ratingand rankingbased data we conducted a nonparametric repeated measure anova 3334 using the artool package in r 35 with respect to the rating measure the result of our analysis shows that there was a main effect of culture main effect of persuasive feature and an interaction between culture and persuasive feature moreover with respect to the ranking measure there was no main effect of culture however there was a main effect of the persuasive feature and an interaction between culture and persuasive feature due to the interaction between the culture and persuasive feature we proceeded to conduct betweengroup and withingroup analyses culture effect based on betweengroup comparison table 3 shows the results of the betweengroup analysis based on the rating and ranking measures the ratingbased result shows a significant difference between both cultural groups with respect to all six persuasive features specifically the result shows that the collectivist group was significantly more likely to be susceptible to all six persuasive features however the rankingbased result shows that the individualist group was more likely to be susceptible to reward than the collectivist group while the collectivist group was more likely to be susceptible to cooperation and social learning than the individualist group similarly the rankingbased result shows that the individualist group was more likely to be susceptible to goalsettingselfmonitoring however the pvalue of the betweengroup statistical significance test was marginal thus more research needs to be done to investigate this marginal difference between both cultural groups with respect to goalsettingselfmonitoring twoway analysis of variance based on culture and persuasive feature given the nonnormality of our ratingand rankingbased data we conducted a nonparametric repeated measure anova 3334 using the artool package in r 35 with respect to the rating measure the result of our analysis shows that there was a main effect of culture main effect of persuasive feature and an interaction between culture and persuasive feature moreover with respect to the ranking measure there was no main effect of culture however there was a main effect of the persuasive feature and an interaction between culture and persuasive feature due to the interaction between the culture and persuasive feature we proceeded to conduct betweengroup and withingroup analyses culture effect based on betweengroup comparison table 3 shows the results of the betweengroup analysis based on the rating and ranking measures the ratingbased result shows a significant difference between both cultural groups with respect to all six persuasive features specifically the result shows that the collectivist group was significantly more likely to be susceptible to all six persuasive features however the rankingbased result shows that the individualist group was more likely to be susceptible to reward than the collectivist group while the collectivist group was more likely to be susceptible to cooperation and social learning than the individualist group similarly the rankingbased result shows that the individualist group was more likely to be susceptible to goalsettingselfmonitoring however the pvalue of the betweengroup statistical significance test was marginal thus more research needs to be done to investigate this marginal difference between both cultural groups with respect to goalsettingselfmonitoring in this subsection we present the withingroup comparisons at the overall and cultural group levels overall withingroup comparison table 4 shows the posthoc pairwise comparisons based on the rating and ranking measures for the overall population sample for the most part in each pair the leftside feature has a higher value than the rightside feature the pairwise comparisons show that there is a significant difference between each pair of features based on the rating measure except for rewardcompetition social learningsocial comparison social learningcooperation and social comparisoncooperation the last three exceptions are applicable to the ranking measure as well in particular goalsettingselfmonitoring regardless of measure is significantly higher than social learning social comparison and cooperation collectivist withingroup comparison table 5 shows the posthoc pairwise comparisons for the collectivist culture there is a significant difference between over 45 and 30 of the pairs of features based on rating and ranking measures respectively for example regardless of measure just as we saw in the overall withingroup comparison there is a significant difference between goalsettingselfmonitoring on one hand and social learning social comparison and cooperation on the other hand however the significant difference between goalsettingselfmonitoring and social learning is marginal 6 shows the posthoc pairwise comparisons for the individualist culture there is a significant difference between most of the pairs of features except for a few over 65 and 85 of the ratingand rankingbased pairwise comparisons respectively with the leftsided feature having a higher value than the rightsided value are statistically significant for example regardless of measure just as we saw in the overall and collectivist withingroup comparisons there is a significant difference between goalsettingselfmonitoring on one hand and social learning social comparison and cooperation on the other hand in addition regardless of measure there is a significant difference between goalsettingselfmonitoring on one hand and reward and competition on the other hand similarly regardless of measure there is a significant difference between reward on one hand and social learning social comparison and cooperation on the other hand finally regardless of measure there is a significant difference between competition on one hand and social comparison and cooperation on the other hand overall and culturespecific persuasion profiles table 7 shows the persuasion profiles of the overall and culturespecific groups they were ordered from the most persuasive feature to the least persuasive feature which was based on either the statistically significant or numerical differences between proximal pairs overall and regardless of culture and measure users were more likely to be susceptible to goalsettingselfmonitoring than the other features moreover based on the rating measure the collectivist group was more likely to be susceptible to all six persuasive features than the individualist group however based on the ranking measure the individualist group was more likely to be susceptible to goalsettingselfmonitoring and reward than the collectivist group on the other hand the collectivist group was more likely to be susceptible to cooperation and social learning than the individualist group we discussed the implications of these findings in the context of tailoring in the discussion section table 7 persuasion profiles based on the perceived persuasiveness of strategies for the overall and culturespecific samples col collectivist culture ind individualist culture the underlined indicates where ind and col significantly differ with respect to each measure with the bolder feature indicating higher users susceptibility indicates marginal significant difference between the concerned pair of features sample discussion we presented the persuasion profiles of our target populations based on six commonly employed persuasive features in fitness applications on the market specifically we presented the level of susceptibility of the overall population sample and culturebased groups to goalsettingselfmonitoring reward competition social comparison social learning and cooperation our analysis of variance presented in section 54 showed that there was an interaction between culture and persuasive feature table 7 shows the persuasion profiles for the respective cultural groups which was based on the betweengroup analysis results shown in table 3 in the betweengroup analysis results out of the 12 betweengroup comparisons nine were consistent with expectations and only three were inconsistent individualist participants were expected to score higher in goalsettingselfmonitoring and reward while collectivist participants in the other features though a number of the group differences were not statistically significant the numerical differences were in the expected directions for example cooperation and social learning were significantly rated and ranked higher by the collectivist group than the individualist group social comparison was rated and ranked higher by the collectivist group than the individualist group though the difference was not statistically significantly competition in particular was significantly rated higher by the collectivist group than the individualist group though competition was ranked higher by the individualist group than by the collectivist group the difference was neither substantial nor significant at p 005 moreover the individualist group ranked goalsettingselfmonitoring and reward marginally and significantly respectively higher than the collectivist group as expected the only unexpected inconsistency with respect to the personal features was the rating of goalsettingselfmonitoring and reward by the collectivist group higher than by the individualist group we explained these results in detail and inconsistencies in the rest of the discussion users susceptibility to personal features overall irrespective of culture the participants were more likely to be susceptible to goalsettingselfmonitoring based on the raring and ranking measures this finding might not be surprising given that a health application such as a fitness application aimed at behavior change might not be considered useful by potential users if it does not have the capability of goalsetting and selfmonitoring in our prior study 17 we argued that every minimally viable health application aimed at behavior change for it to be effective must have at least the functionality of goalsetting and selfmonitoring both of which we considered complimentary fundamental features we considered them complimentary features that must be implemented side by side in a fitness application because it is no use setting goals if the user of the application cannot track hisher behavior towards achieving the set goal this means if a user sets goals then she should be given the opportunity to track his progress towards reaching those goals as well similarly if a user is allowed to track hisher behavior then she should be given the opportunity to set goals to achieve the target behavior 17 for this reason in our storyboards we intentionally implemented goalsetting and selfmonitoring as a composite feature because we viewed them as complementary thus when combined with selfmonitoring goalsetting provides the user with the opportunity to set a target goal and track hisher activities towards reaching the target goal through selfmonitoring the finding that users were most likely to be susceptible to goalsettingselfmonitoring regardless of culture could be said to be consistent with the prior finding by oyibo et al 25 whose studies on persuasion profiles were based on the six cialdinis 24 principles of persuasion commitment reciprocity authority liking consensus and scarcity the authors found that regardless of culture and gender 26 users were more likely to be susceptible to commitment they mapped the cialdinis commitment principle of persuasion to goalsetting as a way of operationalizing it in the persuasive technology domain they explained that goalsetting in persuasive applications is equivalent to making a commitment to the application to achieve a certain goal set for oneself 25 they put it in this way by setting goals especially smart goals the user is indirectly making a commitment to the persuasive system as a result the likelihood of the user performing the target behavior is higher than when no goal is set 17 oinaskukkonen and harjumaa 36 postulated that if persuasive systems support the making of commitments which we operationalized as goalsetting users will be more likely persuaded to engage in the target behavior secondly in our analysis we found that overall and especially for the individualist culture reward was the second most persuasive feature to which users were susceptible for the overall and individualist groups reward was rated as more persuasive than the other features apart from goalsettingselfmonitoring and competition the difference between reward and the other features was significant at p 005 similarly reward was ranked by the overall population and the individualist group as more persuasive than the other features apart from goalsettingselfmonitoring for the collectivist group reward was only rated as more persuasive than social learning and social comparison in general based on the rating and ranking measures it is either reward was rated andor ranked significantly higher than the other features or the difference between rewards ratingranking and the other features ratingranking is not statistically significant this finding is regardless of the cultural group you are looking at as such without considering the moderating effect of culture reward could be said to be the second most persuasive feature to which users are more likely to be susceptible thus in a basic fitness application aimed at changing health behaviors reward should be implemented in concert with goalsettingselfmonitoring to amplify its motivational capability oyibo et al 25 recommended that one way of making goalsettingselfmonitoring more effective in changing behavior is by accompanying it with reward they argued that by providing users with incentives for accomplishing their set goals users are able to visualize in concrete terms the shortterm benefit of their target behavior 37 this is important because most health benefits especially with respect to exercise may not be immediately visiblethey may be longterm andor not physical if not vigorously and consistently performed for a long time thus to encourage users there may be a need to provide them with concrete shortterm nonhealth benefits as a way to reinforce the performance of the target behavior 3839 users susceptibility to social features overall based on the rating and ranking measures among the social features participants are more likely to be susceptible to competition than to social comparison social learning and cooperation specifically based on the rating measure the mean rating of competition is significantly higher than the mean ratings of the other three social features moreover based on the ranking measure the mean rating of competition is only significantly higher than the mean rating of social comparison despite the fact that the mean ranking of competition is numerically higher than the mean ranking of cooperationsocial learning there is no significant difference between them that said given that the mean rating of competition is significantly higher than the mean rating of the other features we recommend that in a onesizefitsall social fitness application the competition feature should be given priority over social learning social comparison and cooperation for the individualist culture in particular competition should be given priority over the others as we saw in the rating measure and ranking measure users from the individualist culture are only likely to be susceptible to competition among the social features specifically we saw that they rated and ranked the other three features way below the neutral value of 4 and the mean value of 35 respectively which is an indication that they might not be susceptible to social learning social comparison and cooperation this finding is consistent with the prior finding by oyibo et al 2737 in the nondomainspecific context of persuasive technology the authors found that individualist users were more likely to be susceptible to competition than social learning and social comparison on the other hand based on the rating measure we saw that users from the collectivist culture are likely to be susceptible to all four social features as they rated them way above the neutral value of 4 moreover the ranking measure indicates that the collectivist users are more likely to be susceptible to social learning and cooperation than competition and social comparison thus we recommend that in implementing a socially oriented fitness application for the collectivist group social learning and cooperation should be given priority over competition and social comparison differences between collectivist and individualist cultures our twoway analysis of variance showed that there was an interaction between culture and persuasive feature based on the ranking measure the betweengroup comparison results suggest that individualist culture is more likely to be susceptible to reward and goalsettingselfmonitoring than the collectivist culture however the collectivist culture is more likely to be susceptible to cooperation and social learning than the individualist culture in particular this finding supports the ratingbased finding in which the collectivist group rated cooperation and social learning significantly higher than the individualist group overall by accounting for the possible influence of culture in the rating of the perceived persuasiveness of the storyboards we based the conclusions of our analysis on the ranking of the persuasive features by the two cultural groups research 14 shows that culture influences the level of criticality in the judgment of hci artifacts moreover we argued that in the rating of the storyboards in terms of the perceived persuasiveness of the illustrated features participants must have taken into consideration the ui design of the storyboards for this reason the individualist participants were more likely to be critical of the ui design of the storyboards than the collectivist participants given that the former were more technologically advanced techsavvy and have higher mobile internet experience in particular previous research 40 shows that users with higher internet experiences are more likely to be critical of hci artifacts when evaluating them in our case table 2 shows that overall the individualist group had higher internet experience than the collectivist group for example only 37 of the nigerian subjects had over 10 years of internet experience compared with 85 of the canadianamerican subjects moreover 29 of the individualist participants had over 20 years of internet experience compared with 0 of the collectivist participants for these reasons we based our conclusions of our analysis specifically on the ranking of the persuasive features as follows the individualist culture is more likely to be susceptible to personal features than the collectivist culture and the collectivist culture is more likely to be susceptible to social features than the individualist culture one plausible explanation for why the individualist culture is more likely to be susceptible to personal features than the collectivist culture while the collectivist culture is more likely to be susceptible to social features than the individualist culture can be found in hofstedes 30 cultural framework the framework defines individualist culture as that type of culture in which people are independent and selfmotivated in the pursuit of lifes goals on the other hand it defines the collectivist culture as that type of culture in which people are interdependent and thus work together to achieve the collective goal of the ingroup to which they belong in our study our two cultural groups exemplify these theoretical underpinnings canada and united states which make up the individualist group are typical examples of individualist countries in the west on the other hand nigeria the collectivist group is a typical example of a collectivist country in africa prior research in the theoretical domain of behavior change has found that the physical activity behavior of individualist and collectivist cultures are driven by personal and social factors respectively for example in the physical activity domain oyibo et al 741 found that selfefficacy and selfregulation are the strongest drivers of physical activity in the individualist culture while social support is the strongest driver of physical activity in the collectivist culture these theoretical determinants of behavior were mapped by the authors to implementable persuasive strategies in the application domain specifically selfefficacy and selfregulation were mapped to personal strategies such as goalsettingselfmonitoring and reward while social support was mapped to social strategies such as cooperation social comparison and social learning the findings of our current study especially with respect to the individualist culture tend to replicate the prior findings in the theoretical domain of behavior change 741 furthermore a plausible explanation for why the individualist group is less likely to be susceptible to social features compared with the collectivist group is the concern about privacy and confidentiality previous studies have shown that people in individualist cultures express great concerns about the privacy and confidentiality of their health information thus in our current study we saw that they are less likely to be responsive to social strategies which may involve other users having access to their health information with respect to the performance and nonperformance of the target behavior overall and culturespecific persuasive design guidelines in our study we uncovered some key findings in the overall and culturespecific persuasion profiles we also found some significant differences between the individualist and collectivist groups we summarize the key findings and significant differences between both cultural groups in the form of design guidelines for developing persuasive health applications especially in the physical activity domain they include the following 1 in a onesizefitsall fitness application goalsettingselfmonitoring should be given priority over other persuasive features followed by reward in other words personal strategies should be given priority over social features in the development of fitness applications targeted at users in both types of culture with goalsettingselfmonitoring and reward implemented in concert 2 in individualist cultures personal features such as goalsettingselfmonitoring and reward should be employed in motivating behavior change if social features are to be employed then competition should be given priority over cooperation social comparison and social learning 3 in collectivist cultures both personal and social features could be employed in changing behavior however in a social context cooperation and social learning should be given priority over competition and social comparison given that members of collectivist cultures tend to work together rather than against one another to achieve collective goals contributions and future work the main contribution of study is twofold expanding the body of knowledge and provision of empirical evidence for the design of fitness apps in the application domain regarding the expansion of the body of knowledge our paper validated culturespecific design guidelines in the persuasive technology domain using social cognitive theory oyibo et al 741 had found that selfefficacy and selfregulation were the strongest determinants of physical activity behavior for the individualist culture and social support was the strongest determinant of physical activity behavior for the collectivist culture thus they concluded that personal factors are more likely to be effective in changing behavior among individualist users than among collectivist users while social factors are more likely to be effective in changing behavior among collectivist users than individualist users our current study was able to replicate and validate this prior finding based on the ranking of the persuasive features we investigated specifically based on the ranking measure we confirmed in the application domain that personal persuasive features are more likely to be effective in changing physical activity behavior among users in the individualist culture than among users in the collectivist culture moreover we confirmed in the application domain that social persuasive features are more likely to be effective in changing physical activity behavior among users in the collectivist culture than among users in the individualist culture in our future work we hope to investigate these findings in the application domain specifically based on the current culturespecific findings we hope to design and implement two versions of a fitness application for both cultures then we would evaluate both versions within and across cultures to uncover how our current findings generalize to the application domain regarding our second contribution in the application domain while it can be argued that the big players in the fitness domain could utilize big data analytics to personalize fitness apps at the individual level this is may not be the case with small players in the field which may lack the required resources for individuallevel bigdata driven personalization moreover big players such as fitbit utilize wearables such as fitbit trackers and bands and commercialize their services 43 which lowincome users especially in africa may not be able to afford the knowledge our paper contributes to the literature will benefit small players who are independent of and not as sophisticated as the big players in the development of evidencebased tailored fitness apps for their culturally diverse target users limitations our study has a number of limitations the primary limitation of our study is that it is based on users perceived persuasiveness of the persuasive features illustrated on storyboards which mocked up a fitness application thus our overall and culturespecific findings might not generalize to the application domain in which users from both types of culture might have to use an actual fitness application in the wild second our storyboards did not exemplify as much as possible the actual visual and user experience design of the fitness application prototype we envisaged in the future due to limited resources on our part at the time this might have impacted the responses of participants across cultures however our current findings sets the stage for a more practical reallife application design in the future which we intended to evaluate in the wild in both types of culture third our culturespecific findings were based on participants whose countries of origin and residence are canadaunited states and nigeria as such our findings might not generalize to other individualist and collectivist cultures hence there is a need to conduct similar studies in other individualist and collectivist cultures as well in the future to test the generalizability of our findings a fourth limitation of our findings is that we did not randomize the order of presentation of the storyboards which could have affected our findings finally we did not take the current physical activity level of participants into consideration in our analysis this is another limitation of our study which could have had an effect on our culturespecific findings with respect to how participants rated and ranked the persuasive features in terms of perceived persuasiveness future work can investigate this as well conclusions we presented the persuasion profiles of users in individualist and collectivist cultures and the differences that exist between them using canadaunited states and nigeria as a case study using rating and ranking measures we investigated their different levels of susceptibility to six commonly employed persuasive features in fitness applications on the market the features include goalsettingselfmonitoring reward competition cooperation social comparison and social learning all of which were illustrated on storyboards our results showed that overallbased on the rating measureusers were more likely to be susceptible to personal features than social features thus we recommend that in a onesizefitsall fitness application goalsettingselfmonitoring should be given priority over other persuasive features followed by reward more specifically our results showed that based on the rating measure users in the individualist culture are only likely to be susceptible to one social feature in addition to the two personal features however in the collectivist culture users are likely to be susceptible to both personal and social features finally based on the ranking measure our results showed that the individualist culture was more likely to be susceptible to personal features than the collectivist culture however based on the ranking measure the collectivist culture was more likely to be susceptible to social features than the individualist culture in future work we aim to validate these findings in an actual fitness application in which the personal and social features were implemented and evaluated in the wild information 2019 10 x for peer review author contributions conceptualization ko and jv methodology ko software na validation ko and jv formal analysis ko investigation ko resources jv data curation ko writingoriginal draft preparation ko writingreview and editing ko and jv visualization ko supervision jv project administration jv funding acquisition jv

persuasive technologies have been identified as a potential motivational tool to tackle the rising problem of physical inactivity worldwide with research showing they are more likely to be successful if tailored to the target audience however in the physical activity domain there is limited research on how culture moderates users susceptibility to the various persuasive features employed in mobile health applications aimed to motivate behavior change to bridge this gap we conducted an empirical study among 256 participants from collectivist n 67 and individualist n 189 cultures to determine their culturespecific persuasion profiles with respect to six persuasive features commonly employed in fitness applications on the market the persuasive features include two personal features goalsettingselfmonitoring and reward and four social features competition cooperation social learning and social comparison we based our study on the rating of storyboards on which each of the six persuasive features is illustrated and the ranking of the six persuasive features in terms of perceived persuasiveness the results of our analysis showed that users from individualist and collectivist cultures significantly differ in their persuasion profiles based on our rating measure collectivist users are more likely to be susceptible to all six persuasive features personal and social than individualist users who are only likely to be susceptible to personal features however based on our ranking measure individualist users are more likely to be susceptible to personal features goalsettingselfmonitoring and reward than collectivist users in contrast collectivist users are more likely to be susceptible to social features cooperation and social learning than individualist users based on these findings we provide culturespecific persuasive technology design guidelines our study is the first to uncover the moderating effect of culture on users susceptibility to commonly employed persuasive features in fitness applications

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key findings what is known and what is new about this study • birthweight data are essential for tracking progress towards the world health organizations global nutrition targets regarding low birthweight by 2025 and as a predictor of neonatal deaths and longterm health outcomes however birthweight data from routine facility data systems are lacking in most of subsaharan africa and south asia despite most births now being in facilities • our study is one of the first to explore perceptions of birthweight measurement in a regional hospital in tanzania we sought to understand factors contributing to the birthweight data gap by documenting equipment availability and assessing attitudes towards measurement by women who had recently given birth health workers and public health stakeholders observation of weighing scales • high quality birthweight information requires functioning calibrated accurate weighing scales the labour and delivery ward used an analogue weighing scale observed to be not calibrated to zero of newborn weighing scales in four other hospital wards two were digital two were analogue and only half were functioning indepth semistructured interviewswhat did we find and what does it mean • collection barriers to high quality birthweight measurement included lack of precise equipment no standardised technical weighing protocols and health worker shortage • perceived value women and healthcare workers highly value birthweight measurement and perceive its use to inform appropriate treatment as needed including medication dosage and to monitor growth this perception created a positive view for high quality facility birthweight measurement • utility perceived poor data quality was reported to limit effective usage of birthweight reported though the health management information systems what next and research gaps • using facility birthweight data is increasingly important for tracking national and global lbw rates opportunities exist to close the data quality gap for facility births notably through improvements in equipment training and human resources implementation research is needed to understand how digital scales and improved weighing protocols and practices can strengthen the quality of birthweight data eg reducing heaping further research is also required to evaluate data flow in routine hmis and if improved quantity and quality of data increases confidence in use of birthweight data background low birthweight is defined as a birthweight of less than 2500 grammes and affected an estimated 205 million newborns globally in 2015 1 over 80 of the worlds 25 million annual newborn deaths are lbw 2 lbw can be a result of preterm birth intrauterine growth restriction or a combination of both compared to normal birthweight infants lbw neonates experience increased morbidity including acute neonatal complications as well as childhood stunting and a risk of adultonset chronic conditions 3 4 5 6 accurate birthweight is important at the individual level to enable provision of lifesaving interventions extra warmth feeding support and increased focus on detection and treatment of complications 78 calculating appropriate drug doses fluids and milk volumes also require a correct birthweight birthweight measurement is an important baseline from which to measure growth for all newborns 9 at population level lbw is also important especially for tracking national targets the sustainable development goals have the first global target to end preventable newborn deaths by 2030 multiple countries are implementing programmes to reach national targets based on the every newborn action plan 10 one of five every newborn strategic objectives is to improve measurement including for birthweight as outlined in the linked measurement improvement roadmap 11 lbw rate is a priority target in the global nutrition targets committed to decreasing global lbw prevalence by 30 before 2025 4 hence policy makers need accurate lbw data to assess progress and target investments 12 accurate birthweight measurement requires newborns to be weighed within an hour of birth using a wellcalibrated scale measuring in 10 g increments 313 to prevent crossinfection a thin clean cloth or paper should be placed on the scale the device is then zeroed the newborn placed on the scale naked and the weight allowed to stabilise before being captured and recorded 914 although true birthweights are normally distributed heaping of birthweight measurements is common in lowand middleincome countries 15 16 17 18 19 birthweight heaping at 2500 g may result in lbw infants being misclassified as normal birthweight in addition birthweight rounding also occurs due to the phenomena of digit bias for numbers ending in 0 or 5 162021 facility births now account for around 80 of births worldwide 22 so facility measured birthweight is an increasingly important data source to track lbw prevalence through the health management information system 123 however lbw data availability remains a challenge especially in the highest mortality burden settings in subsaharan africa and south asia 12223 birthweight data from both household surveys and facilities have been shown to be of mixed quality with high degrees of missing data and heaping 1516202425 in the tanzania demographic and health surveys 2016 report birthweight data were reported for 635 of live births 26 27 28 for homebirths timely birthweight measurement is usually not possible and survey questions to the mother may rely on her perception of birthweight 15 28 29 30 in tanzania facility labour ward birthweight data are aggregated for entry into hmis specifically district health information software 2 thus hmis now has the potential to provide regular birthweight data for the 628 of births that now take place in facilities in tanzania alongside birthweight data from populationbased surveys 28 however concerns regarding the quality of facility birthweight data could limit the usefulness of this data source we identified no previous published research regarding perceptions of women healthcare providers or other stakeholders regarding birthweight measurement in facilities in tanzania or elsewhere in subsaharan africa prior research on value of birthweight has been in settings with high homebirth rates in rural india birthweight was not considered as an important measurement or determinant of newborn health by women their families or health stakeholders 31 similarly in rural bangladesh participants did not prioritise birthweight measurement or recognise its importance for monitoring newborn health 32 this study is nested within one hospital of the five sites in the every newbornbirth indicators research tracking in hospitals study 113334 objectives this paper is part of a supplement based on the enbirth multicountry validation study informing measurement of coverage and quality of maternal and newborn care and aims to identify opportunities to improve quality of facility birthweight data through the following objectives methods setting temeke hospital is a 294 bed regional referral hospital serving a district population of 760000 located in dar es salaam tanzania 35 the hospital was selected as one of two sites in tanzania for the wider enbirth validation study as public hospitals providing the selected interventions for validity assessment of indicator measures this birthweight study took place in only one of these two hospitals to enable the level of detail needed 33 birthweight is recorded in the national standardised hmis book 12 register on the labour ward postnatal mothers and babies are transferred to three wards postnatal ward a after caesarean section postnatal ward b after vaginal births or the kangaroo mother care ward temeke hospital policy admits stable babies weighing 2500 g in the kmc ward unlike the who kmc guidelines which include babies ≤ 2000 g 36 unstable newborns are transferred to a neonatal ward 14 nursesmidwives in the labour ward and 9 nursesmidwives in the kmc ward are involved in measuring birthweight study design this study triangulated the identification and observation of the availability type and appearance of existing weighing scales at temeke hospital within a predominantly qualitative approach objective 1 identify available weighing scales observation was made once by two research assistants on the availability type and appearance of newborn weighing scales at temeke hospital in all wards caring for newborns and mothers labour ward postnatal a and postnatal b kmc and maternal intensive care unit a digital photo was taken of each study scale objective 2 perceptions of birthweight measurement documentation significance and use women enrolled in the enbirth study at temeke hospital after birth of a live born baby or admitted to the kmc ward were recruited after the enbirth exit interview survey temeke hospital nursesmidwives routinely involved in weighing newborn babies were recruited by snowball sampling after an initial interview with a kmc ward nurse once snowball sampling was exhausted purposive sampling was used to recruit nursesmidwives from underrepresented wards women and nursesmidwives were recruited until saturation when the interviews generated no new information kmc ward nurses identified a doctor and hospital administrator who were involved in birthweight data aggregation and use departments of health at the municipal and national level that use birthweight data were identified and recruitment continued until each department had representation written informed consent was taken in the participants preferred language prior to interview all participants were able to provide written consent following review of the literature interview guides on knowledge attitudes and practices surrounding birthweight measurement were drafted translated into swahili and revised for local acceptability the guides were piloted with women who had given birth and nursesmidwives at temeke hospital who matched the study inclusion criteria and revised accordingly guides used for stakeholders were not piloted because of the limited number of stakeholders however due to their semistructured nature the interviews were flexible and able to capture varied responses a tanzanian female research assistant and the first author recruited participants and conducted the indepth semistructured interviews in a private room within temeke hospital or in the stakeholders office interviews were conducted in english or swahili at the respondents preference and when in swahili were translated verbatim in realtime into english by the research assistant interviews lasted approximately 30 min in duration and no repeat interviews were conducted interviews were recorded transcribed translated verbatim anonymised and stored on a secure server an inductive thematic analysis was undertaken using nvivo 10 for data management 37 38 39 the first author read the transcripts for general impression then generated initial codes inductively to improve the trustworthiness of the results multiple researchers commented on and contributed to the grouping of codes with similar concepts into themes and subthemes to create a conceptual framework and interpret findings disagreements in interpretation was resolved by consensus themes were compared across different groups of participants to assess differences and similarities in views results were triangulated among participants and representative quotations were selected coding themes are described in additional file 3 credibility of findings was attained through a prolonged research engagement with the temeke site and through triangulation of data collection methods of responses between populations and of interpretation of results between researchers detailed records were maintained throughout data collection and analysis to strengthen dependability of results some generalisability of the results was supported through purposive sampling of the research site and of respondents results are reported in accordance with the consolidated criteria for reporting qualitative research checklist 40 results objective 1 observation of weighing scales weighing scales were found on four of the five inpatient wards caring for newborns of which only three were functioning the functioning analogue scale in the labour ward usually used for birthweight measurement was capable of weighing in 50 g increments but was noted not to be zeroed with the paper laid on it in the kmc ward one digital scale was functioning and capable of weighing in 10 g increments and a second analogue scale was nonfunctioning in the maternal icu the digital scale had no batteries no scale was found in postnatal ward a and the functioning analogue scale in postnatal ward b was capable of weighing in 50 g increments two themes enablers to accurate birthweight data and barriers to accurate birthweight data and eight subthemes emerged from thematic analysis of transcripts reported enablers created favourable conditions for measuring and recording of quality birthweight data while barriers created disadvantageous conditions enablers to accurate birthweight data parents and community value birthweight every woman described that it was necessary to weigh an infant at birth giving nonspecific reasons for valuing birthweight as an expected component of postnatal care what i know is that a small child should be weighed woman age 24 years temeke tz it is important to know the weight of my baby so that i know where to start taking care of the baby woman age 36 years temeke tz three women reported that they did or would ask to know the birthweight if it were not communicated to them one public health stakeholder described that communities knew on a basic level the importance of a normal birthweight the communities understand the importance of having a baby that isnt underweight you know once they deliver the first thing they ask whether its the relative or the mother how much is the weight they know the importance of having a child who is a normal birthweight they know that probably they are not very much aware when the child is born underweight what are the complications that this child is going to come to get they know it is not good but they do not know what has happened actually with low birthweight public health official age 38 years tz a doctor expressed the opinion that compared to the past women more frequently expect that their baby be weighed after birth and express a desire to know the birthweight although he was the only respondent to identify this trend hospital staff value birthweight every healthcare provider stated that measuring birthweight was an imperative the nursesmidwives and doctor described taking initiative after birth to find and maintain a functioning scale a problem is that the digital weighing scales use batteries that run out all the time most of the time we try to regulate the scales ourselves and we buy the batteries from our own pockets most of the time we report malfunctioning scales to the management and try to bring more digital weighing machines doctor age 40 years temeke tz we will find any means possible to weigh the baby we cannot stop weighing the babies how then will we make drug calculations weighing a baby is compulsory nursemidwife age 50 years temeke tz knowledge of birthweight usefulness women and health workers commonly stated that birthweight was an important measurement as the baseline to monitor the growth of the baby using birthweight to inform medication and treatment was also reported by nursesmidwives and women if a person delivers and they dont know what the baby weighs and the baby is sick when they want to give you medication they will ask what the baby weighs therefore i think there is as importance of knowing the weight woman age 22 years temeke tz doctors and nursesmidwives knew that errors in birthweight measurement could result in dangerous administration of incorrect dosage of various medications for the infant a number of nursesmidwives stated that high birthweight babies could be an indicator of a health problem such as maternal gestational diabetes or that lbw could be a sign of poor nutrition first and foremost a new baby has to be weighed in order to know if there is any health problem woman age unknown temeke tz among women who had given birth to normal birthweight babies the most commonly cited use of birthweight was to monitor growth mothers of lbw babies reported uses of birthweight were identifying health problems and informing appropriate care respondents stated that birthweight data were recorded in multiple documents including the patient case notes and labour ward register labour ward register data aggregated by lbw and normal birthweight is collected daily and compiled into quarterly and yearly reports that are sent from temeke hospital using dhis2 to the subnational and national health offices these reports include summary statistics on the number of lbw babies a public health stakeholder described that collated hospital data are monitored to observe trends in birthweight barriers to accurate birthweight data gaps in knowledge of data utility despite perceiving birthweight as important many women interviewed could not provide specific examples of how such data could be used beyond the reasons described above the public health stakeholders agreed that women have only a general understanding about birthweight importance and attributed this to the womens level of education healthcare providers doubted womens understanding of the value of birthweight especially if they had little education there are mothers who are slow learners you inform them the birthweight but they dont remember it nurse age 50 years temeke tz two nursesmidwives suggested that womens value of birthweight varied depending on whether the weight was low or normal not many of the women understand maybe for premature babies they are very much attentive to them because they have to know if the baby is increasing in weight or not for mothers with babies who have normal birthweight they dont really understand the importance of birthweight nursemidwife age 26 years temeke tz a public health official stated that nursesmidwives were not always aware of the importance of birthweight data people at the facilities they dont even know they are not motivated this data they dont … know the importance of using it they just collect information and they dont know how to take into account how this data can impact public health stakeholder age 38 years tz reported equipment gaps a lack of sufficient and suitable weighing devices was described by every health worker and public health stakeholder as a major impediment to birthweight measurement although most nursesmidwives expressed that they ultimately could find a weighing scale to use many reported that there was no scale in their ward or that it was often nonfunctional yes a lack of scales happens for example right now the batteries in the weighing machine are spent it uses eight small batteries therefore as we plan on how to buy new batteries we dont have a weighing machine nursemidwife age unknown temeke tz even when a scale was available it was sometimes in poor condition devices were described as malfunctioning or giving imprecise measurements participants considered electronic scales more precise than analogue scales however they became inaccurate when batteries ran low participants also reported that it was difficult to determine the precision of their measurements as there were no other working scales to compare it to in the same ward the weighing scale can cause inaccurate measurement … we do not have another machine for comparison if it is giving us inaccurate measurement we can never know nursemidwife age 26 years temeke tz although nursesmidwives knew of hospital technicians who could repair the scales they stated that maintaining and repairing scales was a shared responsibility when asked to describe the maintenance and usage of the weighing scales no healthcare provider mentioned calibration of the scale gaps in human resources for health a frequently cited cause of delayed or inaccurate recorded birthweights was insufficient number of nursesmidwives to care for the growing number of births at the hospital associated with staff exhaustion and errors in both measurement and recording a delay in weighing newborns is due to insufficient staff midwives sometimes you might find only two staffs in the ward helping mothers to deliver babies the whole night and one may get tired and forget to write the birthweight nursemidwife age 26 years temeke tz communication of birthweight to families one doctor respondent suggested the need to improve the communication of birthweight by the nurses midwives to the women so that it is available for them to use as they prefer sometimes it is due to their level of education sometimes it is due to their lack of exposure but mothers are told about the weight of their babies and they forget after a very short time they are taught but they say they dont remember doctor age 40 years temeke tz suboptimal weighing practices nursesmidwives also explained that if a babys weight was not measured at the time of birth the newborn would be weighed at some point during the hospital stay including weighing at discharge if the nurse forgets to weigh the baby at the labour room there is also a nurse who realises that for them to go home she has to weigh the baby … the mother has to be asked the weight of her baby if she tells you she does not know she has to be weighed again nursemidwife age 34 years temeke tz senior nursesmidwives reported that imprecise birthweight measurements may be due to nurses midwives weighing practices some of the nurses might not know how to use the weighing machines accurately it might also happen fig 2 flow of birthweight data through the digital health information system at temeke hospital enbirth study that the nurse hasnt balanced the weighing machine or placed the baby without making sure that the scale is in equilibrium thus making an error senior nursemidwife age 45 years temeke tz one nursemidwife explained that even when a more precise digital scale was available nursesmidwives may prefer to use the less accurate manual scale that they were more familiar with nursesmidwives expressed that often a baby may be weighed clothed or with an additional larger cloth on the scale to prevent the baby from getting cold and to maintain cleanliness however instead of zeroing the scale nursesmidwives subtracted the approximate weight of the clothes in order to calculate a true birthweight in order for the weight of the baby to be accurate you have to weigh the baby when it is naked to get actual body weight sometimes when a baby has complications you can weigh the baby with the clothes on then you minus something like 05 grams for instance a baby might be 37 kilograms then we can estimate the weight to be 36 nursemidwife age 25 years temeke tz the public health stakeholders distrusted the quality of birthweight data from their localities which included the study hospital although they reported monitoring trends in facilityderived birthweight data no stakeholder could report any actions or interventions that had been informed by these trends it was suggested that in future birthweight data could be used to inform the creation of financial priorities or health policies surrounding lbw the fact is that the resources are somewhat limited in the country and lbw data is not being taken to that stage theres no specific intervention maybe the trends in lbw could be used later on but for the time being it has not come out public health official age 38 years tz discussion this study is one of the first evaluations of multistakeholder perceptions of birthweight measurement and data a striking finding is the high value of birthweight reported by all participants women health workers and public health stakeholders women want to know their babys birthweight and nursesmidwives described taking initiative to overcome logistical barriers to ensure that all newborns are weighed whilst birthweight was deemed highly important women remained unclear about the specific uses of birthweight and we found suggestions of uncertainty regarding the precision of measurements concerns were expressed by health workers and public health stakeholders over the value and quality of hospital birthweight data although our findings did not suggest a lack of value by nursesmidwives birthweight data in temeke hospital showed heaping including at 2500 gindicative of imprecision 151718 we identified possible reasons for this imprecision including suboptimal practices when measuring birthweight eg subtracting the approximate weight of clothes after measuring a clothed baby which may have contributed to rounding digit preference or miscalculation though some health workers understood the importance of accurate birthweight measurement the shortage of precise scales was perceived to be a barrier and the labour ward analogue scale was neither calibrated to zero nor capable of weighing in 10 g increments delay in weighing after birth was reported to be due to nurse midwife shortage and resulted in some babies birthweight being measured and recorded at discharge instead of at birth newborns can lose up to 10 of their birthweight within the first few days of life leading to further inaccuracies in true birthweight measurement if there are major delays 41 heaping whereby measures are rounded eg up to 2500 g may lead to underestimation of lbw conversely where birthweight measurement is delayed by a day or more a newborn weighing over 2500 g may then weigh 2500 g due to physiological weight loss hospital birthweight data was being received regularly by the appropriate government offices and the lbw prevalence tracked however they reported that the perceived poor quality of these data impeded its use to set priorities and inform health policies given the reported high value of birthweight measurement by all respondents opportunities exist to improve quality of hospital birthweight data interventions to overcome reported barriers could include appropriate functioning ideally digital weighing scales at all times powered from the hospital electricity supply or with readily accessible batteries standardised weighing protocols including clarity about removing clothes training on precise birthweight measurement techniques improving the quality of birthweight data is crucial so that the data already transmitted through hmis to district and nationallevel can be trusted to be used strengths and limitations a strength of the study is the triangulation of findings using womens health workers and public health stakeholders perspectives the qualitative results provided depth to enbirth quantitative analyses 1718 participants were offered interviews in their language of choice and saturation point was reached during interviewing of women and nursesmidwives which lends support to the adequacy and quality of the findings temeke hospital was purposively selected as an enbirth site for being a typical busy comprehensive emergency obstetric and newborn care facility in tanzania so findings may have some generalisability transferable to other similar hospitals in tanzania or other subsaharan african settings limitations of the study include topics that were not specifically included in the semistructured interview guide such as scale calibration and umbilical cord management were likely underrepresented in interviews we included women from the kmc ward to ensure we had representation from the lbw group but acknowledge introducing selection bias as these mothers are likely to have received more specific education on birthweight lbw which may overrepresented birthweight knowledge future research could importantly assess the perceptions of pregnant women not yet exposed to birthweight practices in the facility it was unfeasible to review results of the research with participants thus weakening the credibility of the findings the study was only in one cemonc hospital in tanzania which limits the generalisability and further research could explore other primary and secondary facility settings to identify other contextspecific interventions to inform improvements in coverage and quality of global birthweight data implementation research is needed to understand how improved weighing protocols and practices can sustainably enhance the quality of birthweight data eg reducing heaping research on feasibility and efficacy of birthweight measurement training for health workers is also necessary further research is required to evaluate data flow in routine hmis and if improved quality of data increases confidence in and use of birthweight data conclusion over the last few decades there has been a large increase in facility births 1 facility measured birthweight has potential to track lbw more regularly than is possible in populationbased surveys 3342 however if such lbw data are to be useful high coverage of accurate birthweights with aggregation for use in hmis are needed the high value of birthweight reported by women healthcare providers and public health stakeholders in temeke hospital tanzania reveals an opportunity to improve quality of birthweight measurements in order to better track lbw prevalence and drive progress towards global and national newborn and nutrition goals 43 future research should establish the feasibility and efficacy of interventions to improve birthweight data quality enbirth study group tanzania nahya salim donat shamba josephine shabani kizito shirima menna narcis tarimo godfrey mbaruku honorati masanja lshtm louise t day harriet ruysen kimberly peven vladimir sergeevich gordeev georgia r gorelangton dorothy boggs stefanie kong angela baschieri simon cousens joy e lawn funding the childrens investment fund foundation is the main funder of the enbirth study and funding is administered via the london school of hygiene and tropical medicine we acknowledge the core funders for all the partner institutions publication of this manuscript has been funded by ciff ciff attended the study design workshop but had no role in data collection analysis data interpretation report writing or decision to submit for publication the corresponding author had full access to study data and final responsibility for publication submission decision competing interests the authors declare that they have no competing interests

background globally an estimated 205 million liveborn babies are low birthweight lbw each year weighing less than 2500 g lbw babies have increased risk of mortality even beyond the neonatal period with an ongoing risk of stunting and noncommunicable diseases lbw is a priority global health indicator now almost 80 of births are in facilities yet birthweight data are lacking in most highmortality burden countries and are of poor quality notably with heaping especially on values ending in 00 we aimed to undertake qualitative research in a regional hospital in dar es salaam tanzania observing birthweight weighing scales exploring barriers and enablers to weighing at birth as well as perceived value of birthweight data to health workers women and stakeholders methods observations were undertaken on type of birthweight scale availability in hospital wards indepth semistructured interviews n 21 were conducted with three groups women in postnatal and kangaroo mother care wards health workers involved in birthweight measurement and recording and stakeholders involved in data aggregation in temeke hospital tanzania a site in the enbirth study an inductive thematic analysis was undertaken of translated interview transcripts results of five wards that were expected to have scales three had functional scales and only one of the functional scales was digital the labour ward weighed the most newborns using an analogue scale that was not consistently zeroed hospital birthweight data were aggregated monthly for reporting into the health management information system birthweight measurement was highly valued by all respondents notably families and healthcare workers and local use of data was considered an enabler perceived barriers to high quality birthweight data included gaps in availability of precise weighing devices adequate health workers and imprecise measurement practicesbirthweight measurement is valued by families and health workers there are opportunities to close the gap between the percentage of babies born in facilities and the percentage accurately weighed at birth by providing accurate scales improving skills training and increasing local use of data more accurate birthweight data are vitally important for all babies and specifically to track progress in preventing and improving immediate and longterm care for low birthweight children

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background patients with symptoms that can indicate cancer often seek care at primary healthcare centers as a first instance making these the main gateway for timely diagnosis and access to secondary care most patients with diagnosed cancer present their sensations in primary care 1 in sweden services that are available at phcs include preventive actions and basic treatments as well as referral to further care 2 primary care practitioners consider cancer as a possible diagnosis almost every day in the clinical setting 1 this is because cancer symptoms are diverse and are usually connected with common bodily sensations for example weight loss diffuse pain or feelings of not being well cancer diagnosis is a complex process that puts high demands on primary healthcare personnel 34 adding to this complexity in the swedish context standardized cancer patient pathways have been implemented since 2015 as an organizational tool for promoting early cancer diagnosis increasing equity in cancer care and endorsing patient satisfaction the ambition with cpps is to standardize the diagnostic process by regulating time frames for specified diagnostic procedures referral to secondary care through cpps is based on welldefined symptoms so called alarm symptoms ie possible signs of cancer cpps intend to shorten the time interval between legitimate suspicion and start of treatment 3 lastly primary care is often associated with gps roles as gatekeepers gatekeeping can either restrict or permit referrals to secondary care by matching patients needs and demands with gps assessment of what the following act will be gatekeeping functions by limiting access to specialist care or conversely building bridges between primary and secondary care 56 the implementation of cpps may create new playing rules for general practitioners by introducing a manual with which to identify people with symptoms indicating cancer which might influence the encounter andersen and vedsted 4 found that standardized guidelines combined with openness and being sensitive to patients presentation of experienced bodily sensations as prerequisites for improving timely diagnosis of cancer 4 thus previous research illuminates the complexity of balancing gatekeeping appropriate use of resources personcenteredness adherence to guidelines and patients wants interaction and negotiation during encounters bodily sensations are defined as a physiological experience whereas symptoms are an interpretation and expression of these embodied sensations 78 the term symptoms refers to subjective evidence of disease while the term signs of illness refers to the objective evidence of diseases 8 the presentation of experienced sensations is a crucial task for patients when interacting with gps in primary care 8 gps meanwhile are tasked with interpreting the presented sensations and thereafter describing them for the patients from a medical perspective during the encounter 9 patients have expertise regarding their own bodies and gps can only gain access to these experiences through the patients presentation of them gps are thereby dependent on patients presentations to be able to make assessments 1011 this turns attention to the ability of both patients and gps to include each other and negotiate one anothers influence in their interactions during the encounter 1213 negotiation can therefore be understood as an ongoing process whereby individuals engage in interactions aimed to attain a certain outcome attainable only through the other party 14 negotiation further encompasses development of shared meanings understandings and agreements getting things accomplished based on joint interest and balance of power 15 one goal of negotiating is to reach a mutual solution through the combination of expertise power understanding and compassion 14 rationale previous research has mainly focused on individual behaviors of seeking care when suspecting cancer 1617 thereby overlooking factors that potentially could be of importance for further access to care such as patientprovider interactions during encounters and standardized care pathways such as cpps additionally standardized guidelines have been described as forcing healthcare professionals to fit patients health complaints into templates to legitimize access to further care 418 and increasing access to further care for those patients who present alarm symptoms 1920 this suggests that interaction and negotiation between patients and gps regarding bodily sensations during encounters in primary care influence the creation of access to further care nonetheless we lack knowledge about how this occurs by creation of access to further care we are concerned not with determining the outcome of access but rather the processes underlying such outcomes aim this study aimed to explore how presentation of bodily sensations were constructed and legitimized in primary care encounters within the context of standardized cancer patient pathways methods design to reach our aim this study employed observations in combination with a constructivist approach to grounded theory method 21 gtm with a constructivist approach assumes that both data and analysis are socially constructed and enable exploration of complex phenomena 22 such as negotiations and interactions between patient and gp observations are an appropriate method for capturing the process of presenting and legitimizing symptoms during encounters an emergent design was employed meaning that data was collected until saturation of our theoretical categories 21 and we followed the coreqchecklist for qualitative studies according to equator guidelines context and setting healthcare in sweden is publicly available tax funded and decentralized twentyone regions share the responsibility of organizing healthcare primary care is most often the first instance for most care as well as the main gateway for accessing secondary care there exist some private primary healthcare providers even though the majority of primary healthcare is publicly organized and financed one of the main obstacles for swedish primary care especially in sparsely populated areas such as the northern region is recruiting and maintaining personnel such as gps inhabitants in sweden have the right to choose the phc they want to be listed at and as far as possible the phc directs the patients all contacts and appointment to a personal doctor to get an appointment in primary care the most common way is to call the phc and primary healthcare nurses will then schedule an appointment if he or she assess it as necessary nowadays patients can also log into the national webbased platform 1177se to make a request for an appointment in primary care which is also managed and scheduled by a primary healthcare nurse observations of patients first encounter at publicly available primary healthcare centers in one county in northern sweden was carried out prior to the study phcs were initially invited to participate through an oral presentation of the study by the researchers during a visit to the phcs written informed consent was thereafter obtained from the head of the phc and from the gps in total twelve phc were recruited purposively to include phcs located in both urban semiurban and rural areas six phcs declined due to time constrains six phcs accepted to participate and observations were conducted at four phcs data collection was carried out between december 2017 and mars 2019 procedure patients were initially briefly informed by the healthcare personnel about the study when the patients called the phc to book an appointment but after the booking had been made thereafter the researchers met up with the patients at the phcs in the waiting room before their booked appointment patients received oral and written information about the study and were given the opportunity to ask questions patients were informed that their decision around participating would not affect their given care written informed consent was then obtained from all participating patients participation was on voluntary basis meaning that participants could withdraw from participating at any time twentysix patients were asked to participate by having their encounter observed of them 18 accepted the gps who were assigned an appointment with the participating patients were thus included in this study in total 13 gps participated the gps work experiences ranged between less than 1 to 27 years and their age ranged between 26 and 62 years see table 1 for characteristics of the encounter and location of the phcs ethical approval was granted from the regional ethical review board observations were conducted by ch and sh two researchers with different backgrounds the observers had the role of observerasparticipants meaning that the observers were visible but passive 23 during the observations ch had an outsider perspective due to no experience of working within a clinical setting sh had an insider perspective due to a background as a registered nurse in ethnographic field studies the emic and the etic perspectives are considered as complementary to each other 23 four observations were during the initial phase of data collection conducted by both ch and sh 13 were thereafter conducted solely by ch and one conducted solely by sh in the beginning of the data collection process ch and sh conducted descriptive and exploratory observations aiming to collect data in an as open manner as possible data was gathered on actions communication and other events that occurred during the encounter without doing any conscious decisions about what was noted since it is essential to have a strategy to systematically collect data when conducting observations 23 we developed a protocol consisting of three sections in the first section actions related to the patients were noted the second section was dedicated to gps and in the third section comments analytical reflections questions and thoughts from ourselves were written down instantly after the observations we audio recorded our handwritten field notes from the protocol which aided us to extend our written notes with our fresh memory of the encounter these audits were then transcribed verbatim for analyzing the empirical material transcripts were then imputed to the software program maxqda version 2018 for coding managing and analysis these descriptive observations were followed by focused observations based on emergent leads analysis coding following grounded theory method 2122 was begun as soon as data became available that is after the first observation the process of coding started with initial coding meaning that transcripts were coded linebyline this step was performed by ch second focused coding was carried out meaning that the initial codes were synthesized to give meaning to larger pieces of data this step was carried out by all authors third theoretical coding was performed to link categories and to specify possible relationships between them theoretical coding was discussed among all authors until consensus was reached see table 2 for an overview of extracts from the coding scheme results the conceptual model developed through the analysis consists of four categories that together build up to one core category negotiating bodily sensations to legitimize access we interpret the four categories as social processes constructed by the patient and gp interactively within which each employed different strategies of negotiating these strategies as we interpret them were created in response to the actors interpretations of the others gestures during the encounter rather than as the result of their conscious planning prior to the encounter these ongoing parallel processes during the blood in stools ♂ 1 ♀ 1 ♀ 1 haematuria ♀ 1 lump ♀ 1 ♀ 1 ♀ 1 ♂ 1 weight loss ♀ 1 ♂ 1 skin lesion ♀ 1 ♂ 1 unusual tiredness ♀ 2 coughing ♂ 1 constipation ♂ 1 twelve women and six men participated at phcs located at urban semiurban and rural areas encounter involved how careseeking was justified how credibility was transmitted how actions were recognized and how expectations were balanced combined these four processes worked to legitimize access to care by negotiating bodily sensations justifying careseeking this category depicted the process of negotiating patients reasons for seeking care in this process patients used different strategies to convey their health problem while gps employed different strategies to understand patients health problem this process highlighted how gps were to a great extent dependent on the patients presentations to be able to negotiate the justification of their careseeking patients strategies consisted of using sensations and emotions to convey their reasons for careseeking when describing sensations patients used their emotions to enhance the relevance of their visit to the phc that is they typically followed up their depiction of sensations with argumentation based on emotions patients carefully described feelings and emotions that the embodied sensations generated in for example anxieties and worries the patient expresses that she is worried since she have had diarrhea and she thinks it might be a sign of something bad patients sought care for their interpretations of alarming changes in their body and gps task was to assess these presented sensations gps strategies consisted of asking questions and gathering relevant information on the experienced sensations to be able to understand patients reasons for careseeking by using questions gps assessed whether the experienced sensations were alarming a potential serious disease or not and when it was relevant they match them to the standardized cpp template for further fasttrack to care as in this example the gp asks have you found blood on the toilet paper yes the patient responds and explains that this is one reason for her careseeking patients argumentation often initiated further questions from the gps who tried to become informed about patients sensations and problems trying to create a picture in order to assess patients problem in accordance to their medical expertise when patients put forth their sensations and problems they were often guided by the gps who asked several questions to get more details about patients reasons for seeking care thereby guiding and steering the encounter these questions pushed patients to respond and provide information the gps requested as ways to understand and accurately assess the experienced health complaints its importance the need and the appropriate level of care corresponding to these the gp steps into the waiting room and calls out the patients name and then show us to her room the patient sits down in one of the chairs next to the desk the gp sits down almost opposite to the patient and says well stomach problem the patient responds yes that is the thing the gp then asks for how long the patient have experienced this problem during encounters patients presented responded and argued for their symptoms and needs while gps asked appraised and reappraised checked and controlled the information trying to ensure that they had comprehended the presented information accurately in accordance to their medical expertise asking leading questions and by that justify the patients reasons for seeking care the encounter starts with the gp talking about the patients medicine and illness history which he had been informed about by reading the patients medical journal he then asks the patient to tell him why she is here at the phc today the patient says that she found blood in her stools a couple of days ago the gp asks if she has experienced that before and how often it has happened since that day transmitting credibility this category depicted the process of negotiating credibility in this process both patients and gps employed different strategies to convey their message and to persuade each other patients employed strategies to convince the gps of the seriousness of their sensations and symptoms gps responded to these strategies by devoting time and attention to listening to the patient this process illuminated how both the patient and gp strived to achieve credibility where patients often visualized their sensations as symptom alarming something serious and gps used both verbal expressions and body language as strategies to appear trustworthy as a response to patients efforts to be taken seriously gps attempted to demonstrate that they were paying attention with verbal expressions patients showed an effort of trying to convince the gps that they were credible and that the information they gave was accurate gps carefully listened to patients stories and reasons for seeking care commonly repeating back what the patient said or signaling their attention by for example saying mhmm or using body language such as nodding to prove that they were listening patients often described situations in detail mirroring an authentic picture and strengthening their reasons for their visits to the phc this was illuminated in situations where patients acted to ensure that the information she or he gave was truthful and based on their own experiences and observations for example patient says the toilet was red and the paper i used when i wiped myself was red patient explains that she looked two times to make sure that it was really blood that she had found on her toilet paper she continues by saying that she was the only one home at that time so the blood in the toilet must have come from her and that she was certain that the blood was not there yesterday gps appeared active and focused during the encounters most often by taking notes which may enhance patients feeling of being taken seriously by asking followup questions gps ensured that they were listening gathering more details about sensations and comprehending given information in order to be able to discern whether there was a serious disease needing a referral for fast medical investigation such as with cpp follow up questions could be about the location of the lump that the patients had experienced in her breast as a way to verify it and assess following expertise and guidelines the patient then gave a distinct instruction on how to detect the lump to convince the gp of the lumps presence and by that convince the gp that her visit to the phc needed to be taken seriously furthermore patients tried to underpin and reinforce their verbal presentation of experienced sensations with body language to visualize their sensations most common patients did not start the encounter with this visualization strategy often this took place during a later phase of the encounter gps reacted to these visualizations by acknowledging the presented sensations and signs by for example asking more questions or initiating an examination the patient tells the gp about her problem with her gall bladder which she also gets medication for during this conversation patient hinge and grabs her stomach the gp then asks is it where you are pointing that hurts yes it is the patient answers conversely when patients sought care for a visible symptom such as a deviant skin lesion it seemed to be less discussion and negotiation between the two parties meaning that patients engaged less in presenting their reasons for careseeking and that gps did not ask as many questions in cases where symptoms were easy to verify by direct observation the gp immediately focused on the lesion itself easy visual and objective clinical findings such as skin lesions appeared sufficient to be considered and thereby legitimized and recognized as a serious alarming symptom needing referral without additional questions and explanations as soon as the gp stepped into the room and put a glance at the patients skin lesion it was verified this type of symptom approval was not observed when patients seeking care for other alarm symptoms the gp steps into the examination room and places himself in front of the patient looks at the skin lesion and says within a couple of seconds yeees well look at that and asks the patient how long he have had this skin lesion seeking and giving recognition this category depicted the processing of negotiating the seeking and providing of recognition it seemed important for patients to present themselves as persons who did the right thing and who sought to make it as easy as possible for the gp they sought gps reactions in the form of acceptance and confirmation of their presented sensations and symptoms while gps showed attention to the situation this process illuminated patients need to be acknowledged as patients who had done the best they could to facilitate examination and gps responses to patients desires for confirmation the process further illuminated patients efforts to be understood and accepted in such vulnerable situations when they felt that they had failed with facilitating the examination or in any other way made it troublesome for the gp patients appeared to want to make sure that they had followed the instructions given before the encounter and get confirmation for doing what they had been told to do for instance patients who had been asked to perform an enema beforehand wanted confirmation from the gp that they had successfully accomplished this task gps confirmed verbally and gently which appeared to help patients become relaxed feel good about themselves and to make them feel that they had done what was expected from them during specific examinations gps verbally explained what they were going to do for example during a rectoscopy examination a couple of minutes passes it is quiet then the gp asks the patient is it going well patient answers yes a while later the gp starts a buzzing machine and stares into the rectoscopy he then explains that he is going to suck out some fluid and that is the thing which causes the buzzing sound patient then asks have i managed to empty my bowel the gp responds by saying it looks good the patient appears relived and says well that was nice in several cases patients explicitly showed that they did not want to cause any trouble or inconvenience for gps and expressed that they tried to ease the examination for example patients asked if they in some way could ease the examination such as adjusting their position in order to help doe the gp to perform it maximally well and facilitate identification of symptoms or disease however in cases where patients perceived that they failed with their task of being a compliant patient or in any other way made it challenging for the gps to perform their job patients apologized for the inconvenience it might cause for example if patients had not succeeded with the enema was sweaty or failed with following instructions for urine sample the patient explains that she during the night found blood in her urine when she urinated which she also found this morning the gp asks if the blood was flowing or gore the patients explains that it was gore blood that she found she also says that she has left a urine sample but that she was unable to wait 4 hours to urinate for the sample as she had been told to do the gp confirms that he understands and says that it is okay anyway balancing expectations with needs this category depicted the process of negotiating expectations of the encounter and reach agreement regarding the next step of care in this process patients and gps used different strategies to fulfil what we perceive as their own expectations and preferences and thereby make the encounter successful for both parties patients employed strategies such as demanding initiating actions and questioning due to sensations experienced as alarming serious illness while gps used strategies to either validate or invalidate patients demands to keep the process on track and when relevant identify valid reasons for referral for fast investigation by standardized cpp this process illuminated how gps as medical experts negotiated preferences by motivating their decisions and choices based on their expectations and needs patients acted and spoke up to become informed get examined or to get treatment gps either validated or invalidated these wishes by accepting or refusing these based on their medical expertise and the standardized template of cpps the patient says i want to rule out certain things it feels good to do what i can the gp replies well we have to see how it goes and how we will do the patient then asks but what test will you do and what can those tell the gp explains that he plans to take both electrolytes calcium and blood status as well as thyroid to rule out any inflammation the patient appears satisfied and says yes i had something like that in mind a challenge for gps appear to be to match patients expectations based on their experienced alarming symptoms with gps medical expertise in order to balance the patients expressed wishes suggestions and expectations gps argued and motivated their decisions to clarify to patients their reasoning behind these suggestions trying to bridge their expectations however even though gps motivated their choices patients did not always automatically show satisfaction and instead continued to argue for their expectations therefore an ongoing polarized discussion sometimes persisted between patients and gps putting additional demands on the negotiation between them when patients appeared dissatisfied with gps suggestions they opposed requested and asked for the things they wanted for example the gp says again that she want her the patient to leave a stool sample the patient asks no blood sample the gp responds and says that she do not think that is necessary the patient questions this decision she arguing for a blood sample by saying that it was 15 years ago since she had her blood tested the gp accepts the patients request she says well okey then shall we take a blood status and a crp indicator for inflammation and infections the patient agrees and appears satisfied with this decision in addition patients requested clarity from the gps and challenged gps to explain and speak straight and clear without hiding any information from them for example it could be stressed by patients that they wanted gps to use the word cancer if needed when communicating information to patients for example after examination the gp gets up from his desk walks to his bookshelf and brings out a paper form he returns to his desk and fills in the form and then says since this is something new and i can feel the lump we will send you for further examination patient replies and expresses that this is difficult but that she also thinks that further examination is necessary the gp brings forward an informative letter about cpp he says you will get an informative letter well it says here … well … it says that … eehm … well the cword is written here the patient then interrupts we can talk about it out loud i have had that thought myself the patient understands that it is cancer that the gp refers to however gps motivated and explained carefully why for example a referral was necessary to make patients understand the seriousness of their health situation and what was going to happen next and why gps motivated their decision by for example referring to and explaining about cpp when further care was needed lastly gps typically ended encounters by asking patients whether they had any questions opening up for dialogue when patients appeared to doubt gps explanations assessment and decisions in terms of diagnosis and further treatment patients often asked controlling questions to reassure that their gp had made the right assessment for example the gp explains that it is difficult to know for sure he repeats the explanation and says one more time that it can be due to scratches in the mucous patient then asks if one would have colon cancer would you sense it gp answers by explaining that it can be displayed in different ways discussion our study demonstrated how bodily sensations were negotiated through four social processes created by patients and gps and that combined to legitimize further access to care negotiation during careseeking encounters has previously been conceptualized as interactive complex processes affected by participating parties 1424 where access to further care and treatment is influenced by context and subjects 25 26 27 hence patientprovider interaction may contribute to differences in treatment and management for patients with cancer symptoms 26 however we found that patients and gps are mutually dependent on each other hence the encounter is reliant on the interaction between the two parties including their different expertise our findings illuminated the challenges of matching expectations of doing as good as possible in accordance to frameworks of guidance and expertise to seek and to give care seemed to be more complex than expected indicating that the role as patient and the role as gp is more than just a person seeking care vs a person giving care the two parties are involved in an asymmetric power relation yet they are mutually dependent on each other and the negotiation during encounters encompasses four social processes described in this study the first social process we found in negotiation during encounters was justification of patients health complaints and symptoms merely presenting worries was not sufficient for legitimization to access to further care patients were required to argue and operationalize their careseeking meaning to be capable to negotiate reasons for careseeking by justifying embodied sensations with the gp this finding is significant because previous research regarding how patients present their sensations is scarce indeed most research about patientprovider communication has solely focused on the provider perspective for instance gps communication skills 242829 in our study gps were challenged to be attentive to patients presentations of complaints and needs therefore they asked questions to get as much relevant information as possible which was needed for assessment of patients problem and reconciliation of their own interpretation of the perceived problem with the patients experience however this illuminates a risk for those who cannot argue for their need of care sometimes gps had to ask specific questions in order to capture the presence of specific alarm symptoms typical for some cancer types which is in concordance with other studies in addition rogers et al 30 also found that if such engagement and searching for specific information when communicating with patients is lacking among gps in primary then there will be a risk of not good and complete comprehension of patients illness experiences followed by inappropriate referral and insufficient care as mentioned previously and in line with our results assessing patients presentation of experienced symptoms of cancer is challenging for gps since many alarm symptoms are ubiquitous of other diseases diverse and often connected with normal bodily sensations hence diagnosing cancer is complex 1431 the complexity of diagnosing cancer challenges the interaction between patient and gp demonstrating the mutually dependence of the two involved parties gps in our study were dependent on the patients presentation of experienced sensations and symptoms and were sometimes required to ask specific questions in the search for specific symptoms while patients were dependent on the gps to have their reasons for careseeking justified hence being given the possibility to access further care the second social process we found in negotiations during encounters was transmitting credibility our results indicated that patients perceived a need to make themselves credible by for example visualizing their sensation or in other ways emphasizing the accuracy and the experienced seriousness of their sensations in addition gps in our study used both body language and verbal expressions for appearing as credible medical experts that patients worked and strived for being perceived as credible was a key finding also reported in previous research regarding patients need of being perceived as reliable when seeking care for symptoms which are conceptualized as medically unexplained 32 we observed that when patients sought care for symptoms that could be easily verified by eye gaze less efforts were put into appearing credible in these cases gps were perceived to put less attention towards patients verbal presentations interestingly the phenomenon of hierarchy between bodily sensations and objective medical signs of illness highlighted in previous literature risør 8 illuminates the gap between the individual patient and the gp which may have an impact on the perception of patients credibility furthermore the counterbalance between vague sensations and what from a medical perspective counts as signs of illness can generate in that gps put most attention to the most prominent complain during encounters 18 the strong focus on the presence of specific symptoms such as alarm symptoms which are valid and legitimized as indicating disease may result in that symptoms which are medically unexplained become devaluated 33 instead healthcare needs to be more sensitive to the complexity of cancer diagnosis 18 hence be more attentive to patients presentations of bodily sensations 33 which may indicate cancer the observed hierarchy of symptoms problematizes the encounter patients with symptoms interpreted by gps as nonalarming or ubiquitous risk being over seen and not prioritized indicating the challenge of the interaction during encounters the third social process we found in negotiations during encounters was giving and receiving recognition we have described how patients strived for facilitating the encounter by for example make it as easy as possible for the gp to perform examination which is also reported in a study exploring the means of being a good patient for adolescents diagnosed with cancer 34 weaver et al concludes that strategies as cooperation minimizing burden and to ease the healthcare professionals task are important features for be perceived as a patient doing good 34 the fear of wasting doctors time have been found among cancer patients especially among those experiencing vague symptoms 3536 and among other patient groups 37 these findings problematize careseeking illuminating patients possible concerns of burdening the healthcare organization if they not perceive their sensations and symptoms as legitimated for seekingcare our results showed that patients wanted confirmation from their gp during the encounter on the other hand derksen et al 38 report in their interview study that gps sometimes perceive that protocol driven care is a barrier for being empathic towards patients during encounters hence adherence to guidelines such as cpps might influence gps provision of confirmation in sum this third social process illuminated mutually dependence in terms of seeking and providing recognition during the encounter patients are dependent on gps recognition to facilitate the encounter and to feel that their contribution to the encounter is acknowledged if gps acknowledge patients contributions to the encounter it could potentially influence patients perceptions of being recognized and confirmed when seeking care the fourth social process we found in negotiations during encounters was balancing expectations patients did often advocate for their wants and needs while gps responded by either validating or invalidating them patients and gps in our study did not always have joint expectations and solutions which caused a polarized discussion with additional argumentations and demands between them andersen tørring and vedsted 18 find that such conflicting situations emerge if vague andor diffuse symptoms are neglected our study illuminated the challenges with negotiating sensations during encounters and highlighted the important and challenging task that gps have namely to interpret patients experiences together with their own medical expertise mutually dependence seem to be prominent phenomenon during encounters while negotiating sensations which needs to be acknowledged lastly to our knowledge there exists no previous study exploring how access is shaped and created during encounters in primary care for patients with cancer symptoms hence this study contributes with important knowledge however our results evoke further questions regarding patients and gps perception of the encounter in this context and in relation to cpps since we assume that there exist more important aspects than those observed and reported in this study the implementation of cpps results in new routines for gps that shapes the extent of their role as gatekeepers harris with colleagues suggests that factors such as funding access to special examinations workload clinical guidelines and relationship with colleagues in secondary care are all influencing gps referral decisions in patients with a potential cancer disease 39 our results visualized the challenges with standardized routines and guidelines such as cpps since we observed that matching patients experienced sensations with symptoms reported in standardized forms are not always an easy task hence cpps seem to influence gatekeeping in primary care and potentially challenges the level of personcentred care which could be problematic since according to scholars personcenteredness 40 communication and dialogue are key factors for quality of interaction 1011 limitations our study has some limitations even though primary care encounters are the main gateway to further care patients attending encounters have already presented sensations that has been legitimized by a district nurse meaning they have been given an appointment to meet with a gp hence being welcomed into primary care this can be seen as a limitation therefore it would be of great interest to study patients presentation of sensations during their first contact with healthcare which is the contact when calling primary healthcare or using webbased platform additionally when conducting observational studies there is always a risk that the observed subject is affected by the observers presence in this case patients and gps however roter and hall 10 states that patients and gps in previous studies have reported that they forgot about being observed furthermore a study comparing video recordings of encounters with gps who knew that they were recorded with gps who was uninformed found no significant differences in neither length of the encounter nor the numbers of health issues discussed during the encounter 41 we believe that these findings are applicable to our study also since the researchers numerous times informed about the aim of the study we assess that the risk of observed subject moderate their behaviors is limited additionally observations as a method for data collection have been found to be informative and a costeffective especially when studying for example quality of care processes and communication observations enable understandings of complex care environments and has been stated to be a valuable method for enabling understandings of complex and dynamic situations 42 such as interactions during encounters also all communication verbal and nonverbal is a dynamic process by using observations as a method for data collection it is possible to gain awareness of delicate behaviors and these dynamic processes 42 conclusion we have shown that the encounter is a complex process encompassing several social processes were negotiation is key we assume that it might be more challenging than expected to be adherent to standardized routines and at the same time employ personcentered care and take patients wants into account patients and gps seem to be mutually dependent on each other and both patients expertise and gps medical expertise need to be reconciled during the encounter the four social processes reported in this study acknowledge the challenging task which both patients and primary healthcare face namely negotiating sensations signaling possible cancer and further identifying and matching them with the best pathway for investigations corresponding as well to patients needs as to standardized routines as cpps based on our results we advocate for a vigilant discussion about how the healthcare organizations can decrease patients experienced need of justifying their care seeking also a confirmative approach towards patients as well as a clear and straight communication would most likely be of help we recommend further research in other regions including metropolitan areas and private phcs we also suggest that future studies adopt and test our model from this study it would be of interest to use the model in focus group discussions with healthcare professionals as well as with medical students to explore if the model is applicable and useful in praxis it would also be of interest to explore patients perception of these encounters supplementary information supplementary information accompanies this paper at 1186s1291302048934 ethics approval and consent to participate ethical approval was granted from the regional ethical review board and written informed consent was obtained from all participants additional competing interests the authors declare that they have no competing interests

background how interactions during patientprovider encounters in swedish primary care construct access to further care is rarely explored this is especially relevant nowadays since standardized cancer patient pathways have been implemented as an organizational tool for standardizing the diagnostic process and increase equity in access most patients with symptoms indicating serious illness as cancer initially start their diagnostic trajectory in primary care furthermore cancer symptoms are diverse and puts high demands on general practitioners gps hence we aim to explore how presentation of bodily sensations were constructed and legitimized in primary care encounters within the context of standardized cancer patient pathways cpps methods participant observations of patientprovider encounters n 18 on 18 unique patients and 13 gps were carried out at primary healthcare centres in one county in northern sweden participants were consecutively sampled and inclusion criteria were i patients ≥18 years seeking care for sensationssymptoms that could indicate cancer or had worries about cancer swedish speaking and with no cognitive disabilities and ii gps who met with these patients during the encounter a constructivist approach of grounded theory method guided the data collection and was used as a method for analysis and the coreqchecklist for qualitative studies equator guidelines were employed results one conceptual model emerged from the analysis consisting of one core category negotiating bodily sensations to legitimize access and four categories i justifying careseeking ii transmitting credibility iii seeking and giving recognition and iv balancing expectations with needs we interpret the four categories as social processes that the patient and gp constructed interactively using different strategies to negotiate combined these four processes illuminate how access was legitimized by negotiating bodily sensations conclusions patients and gps seem to be mutually dependent on each other and both patients expertise and gps medical expertise need to be reconciled during the encounter the four social processes reported in this study acknowledge the challenging task which both patients and primary healthcare face namely negotiating sensations signaling possible cancer and further identifying and matching them with the best pathway for investigations corresponding as well to patients needs as to standardized routines as cpps

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introduction social media is an internetbased form of electronic communication and information digital technology that facilitate social network platforms and applications on line the internet smartphones social media and social networking usage are intertwined with each other in the everyday life and activities of its users in todays postmodern society smartphone play a contributing key role as a devicecumsource for using scrolling browsing and exploring various social media sites namely facebook youtube instagram whatsapp etc these social media sites as a source of application contribute to the flow of information upgrading the knowledge and education news ideas and other trends in the daily lives of the users the usergenerated content on social media defines communication information and interactive technologies thereby play concomitant contributing role to bring about significant influence in todays postmodern society whether it is social cultural economic political health care etc the social media has become an integral part of the internet and digital technologies in india and its digital landscape is expanding rapidly since 2015 the growth of social media in the 21st century of postmodern india by leaps and bounds over the past few years specifically from 2015 onwards has now been playing an increasingly large and crucial role in the lives of its people with more than half of indias population online and the number of internet and smartphones user on the rise social media has become one of the most needed and popular ways of living for the people in the country social media for the people in the country served as a melange of ideas information knowledge and trends of all kinds in the spheres of social educational economic political and cultural apart from entertainment and social connectedness now the argument is that the influence of the usage of social media upon its users have been the consequence of using of internet and social media sites on smartphone mainly as the sources therefore to what extent and nature of social medias influence depend solely upon the users like the extent of its use choice interest need intention and specific requirements to make use of social media naturally the extent and type of use of social media by its users play a significant role in bringing about the nature of its influence upon them this study attempted to elucidate the influence of social media upon its users based on the media ecology theory and analysed the influence of the social media platforms used and its social environment amongst the younger generation rabha users specifically in the context sociology of science and digital technologies and the younger generation review of literature according to postman media ecology is the study of human environments they are concerned about understanding how communication technologies and techniques control the form amount speed distribution and direction of information and how at the same time these configurations or preferences of information impact peoples perceptions values and attitudes velasquez opined that according to postman ideas ecology of media as environment is synthetized in a basic idea technologies which entail communication technologies from writing to digital media they generate environments that affect the everyday life of actors using them for neil postman the word ecology meant the study of environments that is the observation about their structure content and impact on people gamel et al observed that social media platforms rely on digital technologies and computermediated communication to get information the media ecology theory proposed by mcluhan is still relevant as the theory highlights the relationship between subjectivity and social media as the social patterns and interaction formed are linked to the digital culture this according to roslan etal shows how the interface between media technology and communication influence the human environment tiani et al stated that media ecology is a platform that produces an influence on its environment in the context of social media a media ecology is observed when social media platforms influence the behaviour of users as different types of social media platform have different users with different characteristics the development of internet technologies had lowered the barrier to contributing information online almost anyone with internet access could easily blog tweet review comment and updates their facebook status these communication tools have led to an explosion of social media content keeping in mind the influence of use of smartphones and social media usage on its users the citation made by gsma is important which reveals that by the end of 2021 53 billion people subscribed to mobile services representing 67 of the global population in a growing number of markets most adults now own a mobile phone meaning that future growth will come from younger populations taking out a mobile subscription for the first time over the period to 2025 there will be an additional 400 million new mobile subscribers most of them from the asia pacific and subsaharan africa taking the total number of subscribers to 57 billion it implies the potentiality of the younger generation of social media users on smartphones and its influence in the coming years rice et al in their review concluded that despite some challenges with telecommunications access and the social disadvantages experienced by many tribal youths social media presents opportunities given it can have great significance in the lives of indigenous young people whenever the tribal community people have accessed the internet resources and have the device like smartphones to use it is a fact that they actively use the internet and social media sites not only for dispersing their cultural tradition and identity but also to gain information knowledge communication social interaction and entertainment on social media platforms therefore it may be justified to consider that smartphones and social media have an obvious influence on its users of tribal communities because media should be gauged by how they are used and with what effect in terms of social change keeping all above in mind it is inquisitive for the purpose to ascertain the influence visàvis effect of social media usage upon its young generation users of forest rabha tribal community in west bengal india objective to find out the extent of influence of social media usage upon its young generation users of indigenous forest rabha tribe that brought about the changes in their daily lives the following research questions were derived from the objective 1 what about the influence on communication and social networking skills 2 what about the influence on education 3 what about the influence on health and wellbeing 4 what about the influence on culture 5 what about the influence on entertainment materials and methods the primary data was collected by conducting a field survey during the period of septemberoctober 2021 in andu and mendabari rabha forest villages located in the alipurduar district of west bengal india secondary data were obtained from published materials both in print and on websites the qualitative research like case study method was adopted the interview technique was applied for conducting case studies and data collection the snowballcumreferral sampling technique was applied in selecting the informants of case studies criteria for selecting the informants for case studies were i the informants are to be the young rabha ones in the age group between 18 to 30 years ii the informants should have the smartphone for personal use iii the informants are the users of the social media sites iv the education of the informants is to be minimum secondary school examination passed and above internet smartphone and social media proliferation in india the rapid growth and spread of digital technologies like the internet computer laptops smartphones tablets and online social media in postmodern india have created a situation in which it is right to be said that we are moving from the information society to the networked society digital technologies in this postmodern phase play a key role to facilitate users quick and easy electronic communication and mobility of a wide range of content in different spheres of a society smartphones have facilitated easy access to various social media sites and it has become the essential electronic device in the daily life of people irrespective of gender caste class language community and ethnicity worldwide smartphones have the greatest advantage because it remains always with an individual wherever he goes the easy availability of superfast internet at low prices and the decline in smartphone prices are the major reasons behind the massive increase in the usage of the internet and smartphones across india in 2022 the most dominant device in india is the mobile phone with a share of 7591 percent laptop desktop with 2367 percent followed by tablets with 042 percent in postmodern india the digital population across india has increased rapidly and social media has become an integral part of the internet and mobile with internet like smartphones therefore at present the internet and mobile internet have no doubt contributed immensely to the rise and growth of social media users by leaps and bounds all over the country over the few years since 2015 as of february 2022 there are 658 million active internet users and 467 active social media users in india in india the average daily time spent using the internet is 7 hours using the internet on mobile devices 4 hours 5 minutes and using social media 2 hours 36 minutes in india since 2015 there is immense progress on the connectivity side social network user penetration in india was 1913 percent in 2015 which increased to 5044 percent in 2020 and is estimated to be 5831 percent in the current year 2022 the most popular social media platforms in india are whatsapp followed instagram and facebook 49153 million users as of april 2022 there are 467 million unique youtube users in india conceptual framework figure users influence on human environment based on the postmans postulation of media ecology is the study of human environments it is conceptualised that the media digital technologies like internet smartphone and social media influence simultaneously on its users environment specifically in the arena of digital communication and social networking skills education health and wellbeing culture and entertainment findings and discussion the rabha is one of the indigenous tribal communities found in west bengal india ethnically the rabha belongs to the indotibetan group in the past rabhas were a littleknown community in the past their living was conservative and restricted to their own abode in forest villages figure 2 mobile phone ownership by rabha families in forest village findings the total families of study forest villages are 220 of which 882 percent own mobile phone with internet all the informant of the case studies are the users of the digital technologies like internet social media and smartphones they actively up take social media sites like facebook instagram youtube and whatsapp of the total 30 interviews the findings of following 10 key case studies are presented in view of the comprehension of factual unique case of the relationship in between social media and the younger generation of rabha tribe in terms of its effect upon them specifically in the context sociology of digital technologies and the younger generation the followings are the findings of the key case studies of younger generation rabha internet smartphones and social media users 1 age30 genderfemale educationclass ix occupationservice in private sector usersocial media sites like facebook youtube and whatsapp on smartphone according to her the facebook of social media site helps her to connect with people in her community and other community people as well she is engaged as a sales representativeagent of an ayurvedic medicine company social media help her not only to connect with existing clients but also to get more new clients connected from neighbouring and other villages her job is to connect more clients with whom she communicates the details and utility of the companys ayurvedic products and sells them therefore facebook has played a vital role in her case she promotes ayurvedic products on facebook and whatsapp sites she got this job through social media sites one of her facebook friends in another village informed her about the recruitment and other information regarding her present job though she got special training for her present job even then she connects on facebook to those people who are engaged in this profession and get all kinds of help and information she gets all updates regarding her company and profession on facebook she is a divorcee and lives separately while her two daughters are living with their father far away from her residential location because of an unhealthy relationship with her exhusband and inlaws she cannot visit her children quite often in her case she gets all updates about her childrens life on facebook posts she watches and scrolls different entertainment videos or news related to bengali serials movies songs and artists she also listens to different trending songs created in the rabha language version according to her she is benefitted from using social media sites that helped to get her financially independent to connect and communicate in a better way not only with the clients but also with other people and gained many friends it also has helped to get relief and mental peace as well as deal with her loneliness more conveniently and easily moreover it has helped her to get updates about her children besides connecting and interacting with them on social media sites 2 age27 genderfemale educationmaster of arts and bed occupationprivate tutor usersocial media sites like facebook instagram youtube and whatsapp on smartphone on asked how the media benefited her she said she met her fiancé first on facebook who is residing in another village before that she was not aware of the habitation of rabhas also in her fiancés village she is getting knowledge and updates about ongoing fashion trends in india she is enriched with ideas about how to do bridal makeup on tutorial videos on facebook youtube and instagram and decided to apply such gained knowledge of bridal makeup techniques and processes on her already scheduled wedding day she is connected online with her relatives friends and even university friends on social media sites she watches different music other entertainment videos and funny videos on instagram youtube and facebook as well apart from various news and other informative pages she also gets most of the national news and other information on social media platforms so she does not feel aloof and isolated from recent trends news and other related information 3 age27 gendermale educationbachelor of arts occupationwooden furniture and related business usersocial media sites like facebook instagram youtube and whatsapp on smartphone social media keeps him entertained it helps to get relief from stress and boredom as well as gives mental peace when his wife was pregnant she used to watch videos on youtube related to what to eat or not to eat during the period of pregnancy besides exercises suitable for a pregnant woman he also watched all kinds of pregnancyrelated tips information exercise and related videos on youtube for guiding his wife his wife was a graduate student during the pandemic and she used to study by scrolling and watching ba course studyrelated videos on youtube his daughter also sometimes watches cartoons on youtube his friends often share with him various popular songs and music videos translated into the rabha language on social media sites he is amazed that how young rabha girls and boys translate the trending songs into the rabha language 4 age28 genderfemale educationclass x occupationhousewife usersocial media sites like facebook instagram youtube and whatsapp on smartphone for her social media is an important source of entertainment she normally scrolls different videos on youtube whenever she is offmood and during leisure hours besides she watches slots of cooking videos on youtube and facebook moreover she loves to watch different bengali and rabha song videos on youtube her children also love to see free cartoons available on youtube she has many friends on facebook and often chats with them according to her social media helped her to broaden her communication and interaction with others outside the forest village her husband is working in another place where he resides also whatsapp platform helped her significantly to make chat often with her husband by videocalling as well as sharing images of each other it is also helping her to get relief from anxiety about her husbands health and other related family affairs 5 age18 gendermale educationstudent of class xii occupationstudent usersocial media sites like facebook instagram youtube and whatsapp on smartphone during the pandemic and lockdown the school was closed due to the maintenance of social distancing and avoiding any gathering in one place the school authority created their official whatsapp group of students to circulate study notes moreover even the private tuition teachers also circulated study notes to their students on the whatsapp site at that time she was also a member of such a whatsapp group and used to get study notes from her teachers in different subjects for preparation for the final higher secondary examination even her private tutor also circulated study notes on specific subjects so whatsapp platforms played a significant and useful role in disseminating educational content and knowledge to students during the pandemic besides he also used to scroll through youtube videos for study references social media sites are the key sources for him to get relief from boredom during the lockdown it was a very tough time to meeting his friends as a result he started facing mental agony and emotional stress during lockdown and maintenance of social distancing social media during the period of the pandemic helped him to stay connected online with his friends and other known people on instagram facebook and youtube he came to know many facts and information not only at the national but also at the international level he likes to scroll and watches various scientificoriented videos on youtube besides the latest trending songs and funny videos he likes facebook because he can make friends and be friendly with other people in different places he also gets information about trending fashion and other things on social media sites 6 age24 genderfemale educationbachelor of arts occupationstudent of master of arts in political science usersocial media sites like facebook instagram youtube and whatsapp on smartphone she is a big fan of kpop she loves to watch korean chinese and thai dramas she usually comes to know all these on youtube recommendations according to her social media has brought a significant change in her life she is now able to know about other countries on social media moreover on social media she can keep herself updated about new trends in fashion besides information and news at national and at international levels social media has helped to develop her english communication skill and vocabulary she used to get studyrelated references and materials during her final years of graduation by scrolling and watching youtube besides education and knowledgeoriented facebook pages related to her study a few years back her mother died due to suffering from cancer during her mothers suffering from cancer disease she used to watch different doctors lectures and follow their advice on youtube about what to eat and not to eat by a cancer patient after her mothers death she got herself into depression and at that time she could have made a few friends on facebook who used to motivate and encourage her these facebook friends are still in touch with her on facebook so according to her social media has contributed to her mental wellbeing even now she watches some health and medicalrelated videos for her father social media overall has changed her fashion sense also she loves to do indowestern fusion fashion she now feels more confident regarding her fashion and dress sense and choices which is the contribution of social media in her case even her father earlier was not aware of social media and how to use it but now he has become an active user of facebook and whatsapp he also likes to watch some free action movies available on youtube 7 age21 genderfemale educationhigher secondary occupationstudent of fashion designing course usersocial media sites like facebook instagram youtube and whatsapp on smartphone she was interested in fashion from the beginning but being a simple forest village girl never thought of pursuing it as her career though used to watch all kinds of fashionrelated videos on social media like youtube instagram and facebook but when the opportunity came during her final year of school she grabbed that opportunity of studying a fashion design course social media has played a prime role to keep her updated on trending fashionrelated news and fashion trends worldwide for the study course she follows different pages on instagram facebook and youtube for careers and inspiration whatsapp is very convenient for staying in touch online with friends and family in her opinion during the lockdown she not only got her allstudy notes but also was able to contact her professors on whatsapp only instagram and different youtube videos also help to improve her knowledge of the english language she loves to watch korean dramas and kpop music videos on social media she gets all its recommendations from youtube instagram and peer group friends social media not only helps in career building but also keeps her entertained in the case of health her mother sometimes watches health programmes and live bengali news on youtube she is teaching her mother how to use facebook and whatsapp and search for something on youtube on asked what she thinks about the influence of social media in her community and village according to her social media has influenced much on communication like especially the young rabhas are now enlightened with knowledge about the outside world beyond their forest village they have now a keen interest in knowing facts information trend and news beyond their village at regional national and international levels all this has affected positively for instance their lifestyle the process of broad rational thinking and dreams to think bigger in their future career and living like her 8 age20 gendermale educationhigher secondary occupationforest tourist guide usersocial media sites like facebook instagram youtube and whatsapp on smartphone he is a private local forest tourist guide and engaged with local forest resorts in or nearby chilapata reserved forest areas according to him social media have benefited him to gain monetary income almost all the resorts have their promotion pages on facebook besides other official sites so many tourists who wish to spend a peaceful vacation in those resorts which are adjacent to the forest usually get all the information on facebook pages about such resorts he is professionally linked with some of these resorts so whenever tourists come to stay in these resorts the official of these resorts then contact him sometimes tourists especially those of his age form a close bond with him who then starts following him on facebook and instagram mainly to stay in touch continuously with him according to him whatsapp is a more convenient and useful social app in his profession as the majority of the contacts and networks are usually made on whatsapp 9 age22 genderfemale educationclass secondary occupationhousewife usersocial media sites like facebook instagram youtube and whatsapp on smartphone in her free time does facebook she came to know about many other rabhas on facebook from different places besides rabha people she also talks with other community people she feels amazed at how the internet and social media have influenced people especially their community people she feels that before her knowledge about the outside world was very limited but after using the internet and social media she realized that the outside world is really big and there are so many interesting things to know she is quite introverted so she doesnt feel comfortable talking with people which brought her some sort of loneliness but through social media she has made many friends and interestingly she does not feel uncomfortable talking and chatting with them 10 age20 gendermale educationsecondary occupationfarmer usersocial media sites like facebook instagram youtube and whatsapp on smartphone he in his free time likes to scroll and watch facebook besides during work time sometimes he listens to songs and watches music videos on youtube he uses whatsapp sites for communicating interacting and sharing images with his friends and other known persons his friends also send him various popular songs and music videos translated into the rabha language discussion based on the findings of the key case studies on the extent of effects of social media on young generation of rabha users in forest villages the discussion is presented in the following five subsections influence on communication and social networking skills the usage of social media prioritizes the advancement of social interaction between a wide range of people and better digital communication that profoundly changes the way people communicate due to its often use in daily lives it brings new efficiency to digital communication and social networking skills the use of social media among rabhas has created connectivity between their people living in other places to a great extent they are connecting digitally through the usage of smartphones and social media like whatsapp instagram and facebook they are more facilitated to connecting with other rabha people and making connections and companions with different people having various cultural and ethnic backgrounds the young rabhas are now moving towards better digital communication skills exchanging views and knowledge with each other on social media platforms the usage of smartphones and interaction on social media sites helps to get them enriched with new knowledge about their people and other people above all usage of social media sites has also broadened their scope of social network and interaction which was not so earlier even among their parents generation influence on education the use of social media has a very pronounced impact on education whenever it is used for educational purposes internet smartphones and social media are now very prominent sources for collecting educational information text and data it has played a vital role in empowering rabha students and teachers due to the use of a new and easy way of sharing and gathering information thus making their society forward and progress in education educational spread among rabhas was minimal in the past because of their conservative society unavailability of schools and educational infrastructures within or nearby villages and lack of communication and transportation nowadays rabhas can complete their schooling because of the availability of schools within or nearby villages and towns better road transportation and communication for example their literacy rate 3 was 304 percent in 1991 but increased rapidly to 736 percent in 2011 today the young generation rabhas are using different social media platforms like whatsapp and facebook for distributing and gathering study materials youtube is found top among all social media in their list for gathering information they are now diversifying their choices of education usage of social media is of great help for them to collect information about different scopes of academic careers they aspire to consequently some of them also left their respective rabha forest villages to pursue higher studies the strong impact of using social media on their academic life was during the covid19 pandemic situation when the whole educational system of the country rested on digitalization the rabha students at that time were attending their school and college classes online mode moreover they appeared in examinations like others online from their respective homesvillages furthermore they studied different nationallevel competitive examinations on youtube and facebook for a job career resultantly the younger generation of rabhas is found to have a relatively good educational attainment and better educational aspirations as compared to the situation of their parents and forefathers generations they are now competitive in education careers with others in general apart from formal education they are also learning different lessons like cooking lessons sewing lessons and so forth from the usage of social media sites like facebook and youtube these technological and advanced social media sites were not available and accessible even in their parents generation therefore the young rabhas are impressively taking full advantage of the usage of smartphones and social media sites for their academic and job careers influence on health and wellbeing usages of the internet smartphones and social media platforms have become concomitant sources of acquiring information on health and wellbeing the young generation of rabhas is now experiencing and achieving beneficial effects like keep continue better health and wellbeing by using smartphones and various social media sites in their daily lives during pregnancy they usually watch youtube videos for pregnancyrelated tips and information particularly regarding what to eat and not to eat various precautions to observe and different exercises suitable for pregnant ones they follow other yoga channels on youtube to learn yoga for keeping continue their good health they get information on diseases medicines side effects etc from the internet and social media they even take online consultations with doctors and rural health assistants whenever very necessary using social media has become the way for them to overcome and relieve from their daily stresses and refresh their minds they can now connect with their friends neihbours families and relatives on smartphones and social media platforms which are of great help to keep continue better social and mental health and wellbeing influence on culture it can be argued that social media in postmodern society has a very close relationship with culture therefore the usage of borderless social media has an obvious effect on the culture of a community the usage of social media has connected the people and culture within the country and all over the world and thus facilitates the cultural diffusion between people having different ethnic and cultural backgrounds in the case of rabhas the use of social media sites by the young generation has helped not only to cross the boundary of their culture but also created a situation of cultural diffusion among them the rabha tribal community people particularly its young generation are also influenced by social medias cultural contentoriented usages which have grown their interest and curiosity about other cultural trends at regional national and global levels as a result there are changes among them specifically in their taste and interest in other cultural components like music dance food habits lifestyles fashion style and dressing patterns etc at regional national and international levels in the past the rabhas used their traditional music to ingratiate deities after every ritual and feast gradually to date their purpose of performing their traditional dance and music has changed according to time at present besides learning and sharing their traditional songs and dances both young males and females are impressively getting them attracted to bollywood music and dance on social media they learn different indian dance forms such as bollywood dance forms and semiclassical forms they liked to learn and sing bollywood songs and other regional language songs in trend how can they able to know about the trends and learn new songs they come to know this mainly on facebook instagram youtube and whatsapp even they have now been making music cover videos of different bollywood songs in their rabha language which they post and share on youtube facebook whatsapp and instagram they also share reels of bollywood cover dances on instagram and facebook apart from bollywood songs and music they are also fascinated by kpop and westernpop culture they follow different kpop groups and idols bts blackpink exo shinee big bang twice itzy iu gidle aespa got7 etc they are so involved with kpop that they started adopting korean culture in their daily lives by using a few korean words and using them in their local terminological usages they use google translate and youtube videos to understand and learn korean words they watch their favourite kpop idols videos on youtube to know more about them moreover sri lankan yohanis song titled manike mage hithe released in 2020 is also covered in rabha language and uploaded on youtube on 6th september 2021 having 37475 views so far moreover from march 2018 to december 2021 49 rabha video songs including one rabha folk theatre have been uploaded on youtube they are crazy about this song and share it in the community including people other than rabhas they grow their connections in such ways on social media therefore the use of social media is also helping them to keep continue their rabha dialect as well as their traditional songs dance forms and folk theatre these in turn also have contributed to the perpetuation of their traditional rabha cultural identity and language to an extent besides music and dance using social media has also influenced their dress pattern and fashion rabhas have their traditional dress which they weaved themselves in the past and weaving was a part of womens daily household work over the years and the use of social media has facilitated young generation to have now different dress options which was not so in the situation of their elder generations the use of social media usage has influenced upon the fashion and clothing trends among young rabha men and women they follow other fashion influencers and bloggers on youtube and instagram the young male has been styling their hair like celebrities after watching their image and videos on social media they are following fashion at par with the trends on social media and updating their fashion accordingly they have started even doing online shopping according to their requirement from different sites like amazon and flipkart their usage on social media has influenced choice and taste in fashion it helped them make their new fashion ideas like wearing indowestern fusion attire the way of watching and following the fashion culture content on social media in turn has made some of them inspired and persuaded and admitted to fashion design courses according to them using social media on the whole is helping them to update modern trends in every sphere related to their daily lives influence on entertainment social media and entertainment are close associates with each other in the past the only ways of entertainment for rabha community people were traditional dance and singing which used to be performed at the time of their puja celebrations and feasting together however over time their idea of entertainment changed to an extent especially after the young generation of rabhas started to make use of the internet smartphones and social media technology now rabhas watch bollywood and regional language movies for entertainment in their leisure time young rabhas prefer internet surfing exploring new things cultures people and knowledge and connecting with friends on whatsapp youtube facebook and instagram which now are their favourites both the young rabha men and women like to watch southasian dramas namely korean dramas chinese dramas thai dramas and taiwanese dramas on social media sites together with the younger generation their parents also watch hindi dubbed korean dramas movies which are usually telecast sometimes on indian channels their growing interest in southasian dramas came through recommendations on social media like youtube facebook and instagram social media has become their way of relaxation and a budding interest in knowing new things knowledgecumeducation people culture and institutions all of these keep them entertained and that also create instills in them an urge to gain knowledge conclusion and recommendation the rapid growth and spread of digital technologies such as the internet computer laptops smartphones tablets and online social media users in india have contributed to enormous growth of the digital population and social media users over a few years specifically from the year 2015 to 2022 the use of social media by indigenous forest rabha young generation has an impressive beneficial influence on them they are making active use of social media and are getting benefits from the usage of social media platforms namely facebook youtube whatsapp and instagram their proper and positive use of social media has influenced them to improve their knowledge of education in digital communication and skills apart from connecting people these keep them updated about new trends knowledge and different unknown things they benefitted from using education and careerrelated content on social media and that also helped them to walk on the path of progress in the spheres of education and career and aspirations the use of social media helps them to accomplish their curiosity about various cultures people and places the usage of social media helps them to be acculturated with modern trends of entertainment it has changed their music taste dance style modern fashion lifestyles and food habits moreover their growing use of social media and interactions helps them to cope with daily stress and refresh their minds and thus help them continue better mental health as well as improve their knowledge on health and wellbeing moreover social media sites are also used by the young generation rabha users to keep continue their rabha language as well as their traditional songs dance forms and folk theatre these in turn have contributed to the perpetuation of their traditional rabha cultural identity to some extent above all it concludes that there a relationship of digital technologies like internet smartphones and social media with the presentday younger generation of rabha tribe in terms of its influence upon them specifically in the context of sociology of science and digital technologies and the younger generation the study recommends further research on the aspect of changes in the behavioural pattern of the younger generation digital technologies like internet smartphones and social media users of rabha tribe ethical issues addressing to the ethical issues by the researchers is vital for carrying out a research study therefore the ethical standards in this study were maintained in each step and ensured that the informants took part voluntarily for the interview the respondents were informed and made aware that the information to be obtained from them was only for the study and research hence it would not be disclosed to anybody and from them was only for the study and research thus it would not be disclosed to anybody and their privacy and secrecy should strictly be maintained and the researcher only would have the access to them participants were informed clearly that the information they would provide in the survey and during the interview would be kept strictly confidential only the researchers would have access to them such specifics would be destroyed upon completion of data analysis and crosstabulation privacy during the interview process was safeguarded and before interviewing the oral consents of informants was registered moreover while obtaining the consent or conducting interview during the study any form of coercion of the study subjects was strictly avoided and it was entirely relied on the discretion of informants to participate in the interview paper authorship all the coauthors have seen and approved the final version of the paper and have agreed to its submission for publication

digital technologies like the internet smartphones and social media are valuable communication tools to share create and spread information knowledge education communication and social interaction online its rapid proliferation increased the digital population enormously in india their use might have obvious influence on the digital people of the country the purpose was to accentuate the influence of social media upon the young generation users the objective was to find out the extent of the influence of social media upon the young generation of indigenous rabha tribal users and changes in their daily lives the focus of the study was young rabhas aged between 18 to 30 years as this age group is deemed the most susceptible to the influence of social media usages primary and secondary data sources were consulted the case study method was applied for this qualitative study interview technique applied for conducting case studies besides observation the young generation rabhas are adopting and experiencing the active use of the internet smartphones and social media platforms it has brought about changes and progress in daily lives of young generation rabha users social media is also helping them to perpetuate the traditional rabha cultural identity simultaneously it indicates that there is a relationship of digital technologies like internet smartphones and social media with the presentday younger generation of rabha tribe in terms of its influence upon them specifically in the context sociology of science and digital technologies and the younger generation

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introduction in the past decade there has been increasing awareness of the commonalities between the social determinants of criminal behaviour and the social determinants of health including factors such as poverty child maltreatment education and environmental health the description multiple and complex has been used to describe the breadth and depth of the needs of vulnerable populations that span a wide range of social and health issues one significant health issue for people in the criminal justice system is hearing impairment it has been suggested that involvement in the cjs may be a consequence of hearingrelated social problems such as low educational standards unemployment alcohol and other substance abuse other reports have also suggested that people with hi are more likely to encounter language and learning challenges which might lead to challenging behaviours that increase the risk of cjs engagement the association between hi and criminal activity was also proposed in a submission to the inquiry into hearing health in australia which stated that while hi may not directly cause criminal behaviour it does have an impact on selfconcept educational attainment and social skills which in turn increase the risk of criminal activity middle ear disease is a common usually transient childhood disease and is the most common cause of hearing loss in children 2014 kong and coates 2009leach and morris 2017snodgrass and groves 2017 however for aboriginal australian children living in remote communities it is a major public health issue the prevalence of otitis media among aboriginal children living in remote communities in the northern territory of australia is among the highest reported worldwide with a recent survey reporting that almost all children have a history of otitis media in this socially disadvantaged population otitis media tends to affect children early in life tends to be persistent and is often asymptomatic the prevalence of otitis media has been reported to peak at 59 months of age for aboriginal children in australia if left untreated or not treated adequately otitis media often results in conductive hearing loss which reduces childrens exposure to language affects their developmental outcomes and life trajectories the impact of hi in early childhood on the development of children is supported by recent studies which have demonstrated that among nt aboriginal children those children with hi have an increased risk of lower school readiness at age 5 years decreased school attendance in year 1 lower academic achievement in year 3 and increased contact with the child protection system studies have also documented a high proportion of hi among inmates in nt prisons however worldwide it has been claimed that the cjs is currently ill prepared to accommodate people with hi who are both victims and victimizers a vulnerable population which has multiple and complex needs and have often experienced various forms of traumatisation and oppression and are at risk of being further mistreated within the cjs previous studies have demonstrated an association between hi and child maltreatment and between child maltreatment and delinquency however there have been no largescale studies that have investigated the link between hi and juvenile delinquency in the australian aboriginal population these types of studies are important to inform effective prevention and early intervention strategies for juvenile delinquency including in the nt where aboriginal children comprise about 40 of all nt children 2014 2016 and are overrepresented in both child protection notifications and in youth detention centres in the last decade there has been a growing recognition of the importance of a public health approach to child protection and youth justice to improve interagency collaboration and integrated service delivery this same decade has also seen the development of datalinkage infrastructure which has enabled the construction of an nt multiagency longitudinal research dataset to investigate longterm outcomes identify predictors of a range of health and social outcomes and to inform evidencebased interventions 2011 he et al 2019aodonnell et al 2008 royal commission and board of inquiry into the protection and detention of children in the northern territory 2017c by using linked data from multiple agencies this study aimed to investigate the association between hi in early childhood and youth offending to inform interagency collaboration in the provision of effective and culturally responsive early intervention programmes to vulnerable children and families we believe the findings of this study will have important implications for the recent australian governments closing the gap refresh and the nt governments reform implementation plan methods study design and cohort selection this is a retrospective cohort study which used linked deidentified individuallevel administrative data from four government agencies the study cohort was all aboriginal children born in the nt between 1st january 1996 and 31st december 2001 with complete audiometric records and who attended an nt government school in the remote and very remote regions at year 7 the records for children from the nt remote hearing assessment dataset were linked to nt perinatal registry data and nt government school data to define the study cohort hospital inpatient data were used to exclude children with a history of hospital admission for otitis mediarelated surgery before the age of 4 years under the premise that early surgery may alter the outcome of hi on child development the selection process for the study is presented in fig 1 after selection there were 1533 children in the study cohort who completed a hearing assessment between 2007 and 2015 data sources data was obtained through the nt child and youth data repository which had been previously developed as a collaboration between menzies school of health research and nt government agencies for this study six core datasets were used the nt perinatal data register is a statutory register with information recorded for all births in the nt the remote hearing assessment dataset contains clinical information for all children assessed by nt remote hearing services nt remote hearing services is an outreach service that assesses children referred through the community clinic overall it has been reported that 18 of nt aboriginal people aged under 21 have received the service the nt government school dataset contains public school enrolment and attendance data the child protection dataset includes statutory records of children with any contact with child protection services and includes information on all notifications of possible maltreatment substantiated cases and placements in out of home care all adults are mandated under nt legislation of the care and protection of children act 2007 nt to report events in which there is reasonable concern that a child has been harmed or is at risk of harm notifications and substantiated cases are classified as one of four types of abuse or neglectemotional abuse physical abuse sexual abuse or neglect the nt hospital separations dataset is a single dataset containing hospital admissions data for all six nt public hospitals the hospital data was used to identify children who had had surgical procedures related to otitis media the sixth core dataset was the nt integrated justice information system which contains records for individuals charged with an offence and the results of subsequent justice assessments analysis outcome variable the outcome variable was youth offending which was defined as the first record of an offence that have been proven guilty in the courts proven guilty offences were chosen instead of convictions because under the youth justice act 2005 local court judges have discretion whether or not to formally record a conviction even when charges have been legally proven key explanatory variablehearing impairment in our study hi was determined from the first audiometric assessment result for each child in the remote hearing assessment dataset under the assumption that the first assessment result was representative of a childs hi status in their early years this assumption is supported by previous findings that om in nt aboriginal children develops early in life is persistent and asymptomatic and is not diagnosed until an older age due to easier diagnosis and greater healthcare access in the nt remote hearing service hearing assessments were performed using pure tone audiometry with results reported as the average threshold of hearing for the three frequencies 500 hertz 1000 hz and 2000 hz the result for each ear was classified as either normal or one of four levels of hearing loss namely mild moderate severe and profound a comparatively conservative classification which has been deemed more suitable for children aged under 15 only results of conductive and mixed hearing loss were included in the study based on these hearing results we have derived the hi variable as a categorical variable containing four mutually exclusive categories normal hearing normal audiometry results in both ears unilateral hearing loss normal in one ear and any degree of hearing loss in the other mild hi mild hearing loss in the better hearing ear moderate or worse hi moderate or worse hearing loss in the better hearing ear other explanatory variables in the nt the minimum legal age of criminal responsibility is 10 years therefore we chose the explanatory variables that were available close to age 10 to identify opportunities for agencies to intervene to prevent first delinquency these are the proxy variables for the underlying factors of delinquency in which the links to delinquency have been documented in previous literature 1 child maltreatment experience was constructed from the child protection data based on the primary types of child maltreatment notification before entering year 7 at school this is an ordinal variable with six mutually exclusive categories no notification of maltreatment neglect only emotional abuse only physical abuse only sexual abuse only and multitype maltreatment when more than one maltreatment type is recorded for a single event the primary maltreatment type is the one which is the greatest immediate risk to the child when a child has been reported for different maltreatment types in more than one child protection notification before year 7 the child was deemed as having multitype maltreatment before year 7 2 school engagement was constructed from the school attendance data defined as the proportion of school days attended in year 7 a categorical variable with three levels less than 60 from 60 to 80 and more than 80 attendance aboriginal status to resolve inconsistency of the recording of aboriginal status between datasets the aboriginal status variable was derived from a hierarchy of accuracy which was based on systematic evaluation of the completeness and quality of each dataset referenced to health records for which an audit in 2011 demonstrated 98 consistency between recorded aboriginal status and patient interview this approach is described in detail elsewhere and is consistent with best practice guidelines involving data linked from two or more datasets statistical analysis all statistical analyses were conducted using stata for windows version 15 analyses were stratified by sex based on literature suggesting different mechanisms and developmental trajectories leading to offending between males and females survival analysis methods were used to examine the association between hi and a record of youth offence survival time was defined as the time in years from the tenth birthday to the occurrence of first proven guilty offence and children who had not committed first offence were censored at the earliest of the following date of death the last observed date in the linked data or the end of the study period on 31 december 2017 the timescale for the survival analysis was the age of children in years information on last contact with a child recorded in the data repository were used for recording whether a child remained in the nt these datasets include health education death registration child protection and juvenile justice data this step avoids the risk of including children in the analysis who may have migrated out of the nt and for whom there would be incomplete records the kaplanmeier estimator method was used to estimate the cumulative proportion of first youth offence which describes the proportion of the population which is estimated to have experienced the event over time the cumulative proportion was estimated for each of the four categories of hi in the multivariable analysis the cox proportional hazard method was used to examine the association between hi and the youth offending given the characteristics of our study cohort the targeted outcomes of children from the same community are likely to be correlated to account for any intragroup correlation the standard errors were clustered at the community level to account for cohort effects a separate baseline hazard rate was estimated for each birth cohort the royston r 2 measure was used to estimate the separate contribution of each risk factor in the variations in youth offending the royston r 2 measure has been previously used in a queensland study to quantify the contribution of healthrelated factors for reincarceration and in a swedish study to estimate the proportion of variation explained by prior criminal history factors it has also been used to investigate the contribution of various factors in explaining the risk of readmission following surgery in the united states results selected baseline characteristics for boys and girls in the study cohort are presented in table 1 the majority of the study cohort resided in areas that were in the most socioeconomically disadvantaged category by irsd and very remote more than onethird of the cohort had been reported to the child protection system before year 7 over 70 of children were recorded as being enrolled by their mother at year 7 and more than 40 recorded an attendance rate of 60 in year 7 the median age of the first audiometry test was 102 years in both boys and girls almost half of the study cohort had uhlhi among the children in our study cohort with no history of an offence 461 of boys and 490 of girls had uhlhi among the children with a record of being found guilty of an offence 556 of boys and 367 of girls had uhlhi cumulative proportion of first proven guilty offending figure 2 shows the kaplanmeier failure curves of first proven guilty offence for both boys and girls with varied levels of hi for each level of hi boys had a higher risk of offending than girls the univariate analysis revealed the difference in the association between hi and offending for boys and girls for boys those with moderate hearing loss had the highest cumulative proportion of youth offending followed by boys with mild uhl and normal hearing for girls those with normal hearing had the highest cumulative proportion of youth offending followed by girls with mild moderate and uhl factors associated with offending the risk of offending was significantly higher in boys with a record of moderate or worse hi and those with mild hi than in boys with normal hearing in the univariate analysis these associations were attenuated when child maltreatment school factors and community fixedeffects were added to the multivariable model with no evidence for an association between hi and offending in the multivariable model for boys risk of youth offending was found to be significantly higher for children reported for more than one type of maltreatment before year 7 followed by physical abuse only and neglect only risk of youth offending was found to be significantly lower for boys with year 7 attendance between 60 and 80 and above 80 based on community where the children go to school at year 7 033073 p 0001 than boys with year 7 attendance less than 60 for girls the association between hi and offending was not evident in either univariate nor multivariable analysis in the multivariable analysis the risk of offending was higher for girls with multitype maltreatment and physical abuse only there was also strong evidence for a lower risk of offending for girls who were enrolled by mothers at year 7 contribution of individual categories in explaining the variations in offending in the fixed effect model the contribution of explanatory variables factors in explaining the variations in offending was quantified using the royston r 2 measure the multivariable model explained a greater proportion of the variation in offending for the girls than boys hi contributed 65 of the variation in offending among girls but 32 for boys at the individual level the variation in youth offending was partially explained by child maltreatment notification before year 7 and year 7 school attendance enrolment by mother at year 7 also explained some of the variation in offending for girls but not for boys community fixed effects accounted for the greatest proportion of explained variance for both boys and girls discussion this study is the first to use multiple linked administrative datasets to examine the association between audiometricallydiagnosed conductive hi and youthoffending among australian aboriginal children the study has also quantified the relative contribution of hi and other markers of social wellbeing and engagement as predictors of youthoffending our analysis found that the pattern and magnitude of association differ between boys and girls for boys both moderate or worse hi and mild hi were associated with higher risk of offending in the univariate analysis although in both categories the association was attenuated in the multivariable model no evidence for an association was found in either the univariate or the multivariable model for girls the reasons for the lack of an association for boys after adjustment for other factors is unclear however it is possible that any impact of hi was masked by the much stronger impact caused by the experience of child maltreatment and community factors high rates of hi among aboriginal children in the justice system our study demonstrates that the prevalence of hi among aboriginal children with a record of an offence is high which corroborates the results of a previous study on hi among adult inmates in darwin and alice springs prisons as previously described the high rates of hearing problems among nt aboriginal prisoners raises concern about their ability to communicate with corrections staff a situation that can be exacerbated for those for whom english is not their first language given that aboriginal youth make up 96 of all youth justice detainees in the nt and that the nt has the highest prisoner recidivism rate in australia addressing the high rates of hi in aboriginal children and improving the response of the justice system to hearing impaired aboriginal people may be a critical step in reducing aboriginal incarceration rates these findings support the need for additional support for young detainees and prisoners with hi including routine hearing assessment for new detainees better access to hearing aids sharing results of detainees past hearing assessments by the health department with police and the courts and improved training for police the judiciary and correctional staff in identifying the signs of hi among individuals and ways to improve communication with them child maltreatment and youth offending our study also reaffirms findings from previous studies of an association between exposure to child maltreatment and youth offending our results provide new insight into the separate association between child maltreatment notification and youth offending for boys and girls in the study cohort second to community factors child maltreatment notification explained the largest proportion of variation in youth offending for both boys and girls the highest risk of youth offending was found in children reported for more than one type of maltreatment this finding corroborates the results of a previous study which found that a high proportion of aboriginal children recorded in both the nt child protection and youth justice system had been reported for all four types of maltreatment this result supports the development of targeted intervention programs for children who have contact with child protection particularly those who have been notified for multiple types of maltreatment in order to prevent later contact with the youth justice system school attendance and youth offending our study provides encouraging evidence that increased school attendance in year 7 is associated with a lower risk of offending particularly for the boys this result supports efforts to maintain the engagement of students to prevent later contact with the justice system more than twofifths of the study cohort had a school attendance rate of less than 60 this finding is consistent with previous research that reported a decline in school attendance from year 6 onwards with average attendance rates for aboriginal children living in very remote regions dropping from almost 70 in year 5 to less than 60 in year 7 in this context promoting and maintaining student engagement in school is particularly important during the middle years and is consistent with previous studies that have reported the mediating effects of school engagement in the relationship between maltreatment and delinquency community factors and youth offending our study found that community factors explained the greatest proportion of the variation in youth offending in remote communities limitations there are several limitations to the study firstly not all aboriginal children living in remote areas accessed the ear health outreach service and not all attended government schools care must be taken with generalisation of the results to all nt aboriginal children or all aboriginal children living in remote communities the new hearing for learning program is expected to increase the proportion of young nt aboriginal children receiving regular ear and hearing assessment with the potential for more representative data a second limitation is that the availability and timing of the hearing assessment made it necessary to use each childs first audiometry result for analysis under the assumption that the result was indicative of longterm hi status of a child as most of the children in our study cohort had their first audiometric assessment at middle childhood the prevalence of chronic middle ear disease peaks at early years then declines through childhood there may be children whose development was affected by hi at an earlier age but who later have improved hearing these cases will result in misclassification leading to an underestimation of the strength of association between a record of hi and youth offending a third limitation is that the outcome measure of proven guilty is a precise but narrow measure of youth offending as other datasets such as police data become available there is opportunity to extend the research on hearing impairment to other measures of offending including apprehension by police and referral to youth diversion programs with more comprehensive linked data on youth offending there is also opportunity for analysis of other dimensions of offending such as the age of first offending and the frequency of offending a final limitation is that there are other factors such as child and parental hospital admissions that may be important confounders but which were not available for inclusion in the multivariable models conclusion our study confirms a high prevalence of hi in remote aboriginal children with and without offending records there was evidence in univariate analysis for an association between hi and youth offending for boys only however this association was not evident after controlling for other risk factors our findings highlight the complex range of factors that underpin youth offending for remote aboriginal children including the relatively greater impacts of child maltreatment and community factors on youth offending than hi and the different risks for youth offending between boys and girls these findings point to opportunities for early intervention to disrupt the pathway into the youth justice system and provide a clear message for governments policy makers and community service providers about the urgent need for interagency collaboration to meet the multiple and complex needs of vulnerable children in the northern territory authors contributions vh was the data analyst and drafted the initial manuscript sg jy cm dh al and tw contributed to the design of the study and the analysis plan all authors contributed to the interpretation of the results revisions of the draft manuscript and have approved the final version for publication funding the study has been supported by funding provided by the australian department of prime minister and cabinet through the project entitled linking nt and australian government data to improve child development outcomes as well as northern territory departments of health education children and families and attorney general and justice through the child and youth development research partnership the funding body had no involvement in the study design data analysis interpretation of data or preparation and publication of research papers competing interests the authors declare that they have no competing interests

background high prevalence of chronic middle ear disease has persisted in australian aboriginal children and the related hearing impairment hi has been implicated in a range of social outcomes this study investigated the association between hi in early childhood and youth offending method this was a retrospective cohort study of 1533 aboriginal children born between 1996and 2001 living in remote northern territory communities the study used linked individuallevel information from health education child protection and youth justice services the outcome variable was a youth being found guilty of an offence the key explanatory variable hearing impairment was based on audiometric assessment other variables were child maltreatment notifications year 7 school enrolment by mother year 7 school attendance and community fixedeffects the cox proportional hazards model was used to estimate the association between hi and youth offending and the royston r 2 measure to estimate the separate contributions of risk factors to youth offending results the proportion of hearing loss was high in children with records of offence boys 556 girls 367 and those without boys 461 girls 490 in univariate analysis a higher risk of offending was found among boys with moderate or worse hi hr 177 95 ci 105298 and mild hi hr 154 95 ci106223 this association was attenuated in multivariable analysis moderate hi hr 143 95 ci078262 mild hi hr 137 95 ci 083226 no evidence for an association was found in girls hi contributed 32 and 65 of variation in offending among boys and girls respectively factors contributing greater variance included community fixedeffects boys 146 girls 365 child maltreatment notification boys 142 girls 239 and year 7 school attendance boys 79 girls 121 enrolment by mother explained substantial variation for girls 254 but not boys 02 conclusion there was evidence in univariate analysis for an association between hi and youth offending for boys however this association was not evident after controlling for other factors our findings highlight a range of risk factors that underpin the pathway to youthoffending demonstrating the urgent need for interagency collaboration to meet the complex needs of vulnerable children in the northern territory

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introduction the estimated prevalence of homelessness in the general adolescent population is between 9 and 15 1 resulting in almost 2 million homeless and runaway youth 2 these homeless youths are much more likely than housed youths to engage in injection drug use including injection of methamphetamine and other stimulants 3 highrisk sexual activity is another prevalent behavior that coupled with idu puts homeless youths at risk for the development of infectious diseases such as acquired immunodeficiency syndrome 4 and hepatitis 5 correlates of drug use among youth several studies have been undertaken to identify correlates of drug use among youths age and duration of homelessness have been associated with idu among homeless youths living in san francisco 3 results from a systematic review showed that ethnicity risky sexual behavior a history of heroin or other opiate use and a family history of drug use were all associated with methamphetamine use among youths living in north america and asia 6 one study of housed young women showed that methamphetamine use was associated with having a methamphetamineusing partner 7 stimulant use and young adults cocaine and methamphetamine are two of the stimulants most commonly used by youths 8 stimulants elevate mood increase general feelings of wellbeing and enhance energy and alertness 9 which makes them particularly attractive to homeless persons young adults have a higher rate of cocaine use than any other age group national institute of drug abuse nida 8 methamphetamine use is also prevalent among young populations 45 of 12 th graders 41 of 10 th graders and 31 of 8 th graders have reported lifetime use of this drug 810 adverse health effects of continued cocaine use include cardiovascular disturbances seizures and even sudden death 10 adverse effects associated with continued methamphetamine use include memory loss aggression psychotic behavior heart damage malnutrition and severe dental problems 10 perinatal effects are premature delivery placental abruption fetal growth restriction and heart and brain abnormalities 11 dangerous behavior associated with stimulant use among youth in addition to having general adverse health effects stimulants can also produce lowered inhibitions feelings of invincibility heightened sexual experiences hyperactivity 6 and paranoia 12 these effects can in turn increase the likelihood of dangerous behavior compared to young men who do not use stimulants young men who use stimulants report less frequent condom use a greater number of female partners and greater exchange of sex for money or drugs for young women stimulant use is associated with reports of more sex acts 13 with a greater number of partners 7 use of stimulants can also lead to poor academic performance stealing and violence as well as transmission of infectious diseases 14 theoretical foundation for the studythe comprehensive health seeking and coping paradigm 15 served as the framework for the proposed study this model has been successfully applied to investigations focusing on understanding hiv hepatitis b and c virus risk and protective behaviors and other health outcomes among drugabusing homeless and impoverished adults 16 17 18 19 20 and youth 2122 the chscp provides a foundation in exploring the importance of various cognitive and behavioral domains in relation to the selection of variables in this study namely sociodemographic variables mental health sexual activity and risky drug and alcohol use the first of seven components includes a variety of antecedent variables such as sociodemographic factors including age gender ethnicity employment status and foster care and incarceration history mediating components include personal social psychological and behavioral factors outcome variables includes risk behavior this study examines characteristics of young homeless cocaine and methamphetamine users in an effort to identify correlates of stimulant use findings can help health care providers better identify persons at risk for the development of stimulant use behaviors and conditions and inform the development of substance abuse prevention programs for atrisk homeless youths 6 methods this crosssectional study uses baseline information from a pilot longitudinal intervention study on hepatitis a and b vaccination among homeless youths baseline data were collected between february 2009 and july of 2009 the study was approved by the ucla human subjects protection committee and has been described in detail elsewhere 23 participants and setting eligibility criteria for the longitudinal study included a being homeless b aged 1525 years and c actively engaged in drug use for the last six months a convenience sample of 156 homeless youths was recruited from a dropin site in santa monica california that served homeless youth procedure homeless youths were informed of the study by flyers posted at the site following written screening consent research staff conducted a brief eligibility assessment to obtain information about basic demographic characteristics texas christian university drug screening items 24 homeless status and hepatitis b vaccinerelated factors research staff then obtained a second written informed consent from eligible homeless youths administered a baseline questionnaire paid participants 10 for completion of the screener and baseline questionnaire and randomized participants into intervention and control groups measures sociodemographic variables collected at baseline by a structured questionnaire included age ethnicity gender education and histories of sexual partners and foster care based on preliminary analyses age was dichotomized at 20 or older education was dichotomized at high school or equivalent and number of sexual partners was dichotomized at its median of 10 dangerous sexual encounters were assessed by an item asking about trading sex for money drug and alcohol use were measured by a modified tcu drug history form 24 this questionnaire has been tested with drugusing homeless adults and youth 25 it records the lifetime and current use of 16 drugs used by injection intradermally and orally drugs assessed included the outcome measures of cocaine and methamphetamine as well as heroin inhalants hallucinogens and alcohol an item assessing use of nicotine was added to the questionnaire social support was measured by an item that inquired whether social support came primarily from drug or alcohol users nonsubstance users or equally from substance and nonsubstance users or whether there was no social support for regression analyses social support was dichotomized as any versus none the cesd depression scale 26 assessed mental health this 20item scale measures depressive symptoms on a 4point continuum ranging from 0 to 3 the cesd has wellestablished reliability and validity and has been used in a wide variety of populations in this study reliability for the cesd was 91 the 20 individual item scores were summed to construct the cesd scale all instruments and items have been previously tested modified and validated using homeless populations data analysis unadjusted associations of cocaine use and methamphetamine use with sociodemographic physical health and behavioral measures were examined with chisquare tests variable selection was guided by the chscp 15 because of the relatively large number of correlates stepwise backward logistic regression modeling was used to assess independent associations between each of the stimulants and sociodemographic health and behavioral measures the initial model for each stimulant contained variables that were related to that stimulant at the 15 level in unadjusted analyses the 10 level was used for retention variables in the final models were assessed for multicollinearity and model goodness of fit was checked with hosmerlemeshow test analyses were conducted using sas version 913 results almost threefourths of participants were male and between 20 and 25 years of age the sample was also primarily white educated through high school acquainted with the juvenile or adult justice system and depressed over onefourth reported injection drug use and over half reported 10 or more lifetime sex partners over half the sample used each of the stimulants as shown in table 2 a number of factors including older age a juvenile halljailprison history idu having at least 10 partners and having traded sex for money were associated with both cocaine and methamphetamine use in unadjusted analyses having a high school education or equivalent social support and recent alcohol use were associated with cocaine use but not with use of methamphetamine not reporting faith and having been in foster care were associated with methamphetamine use only although raceethnicity was not associated with stimulant use in overall analyses subanalyses indicated that african americans were less likely to use cocaine than whites in logistic regression analyses idu was the only common correlate of use of each stimulant with injection drug users having over 7 times greater odds of using stimulants compared to nonusers of injection drugs other positive correlates of cocaine use were reporting 10 or more sex partners and use of alcohol in the past 6 months african americans were less likely to report cocaine use than whites youths lacking social support also had lower odds of reporting cocaine use than those with more support youths with a history of foster care and those who had been in juvenile halljailprison had over 3 times greater odds of methamphetamine use than their counterparts without these histories older age and trading sex for money were also associated with methamphetamine use controlling for potential confounders discussion our study results show that there are several factors which correlate with cocaine and methamphetamine use among homeless youth in unadjusted analyses in particular we found that idu having had at least 10 sexual partners and having traded sex for money were associated with both cocaine and methamphetamine use these findings are consistent with findings from other recent studies for example injection drug using youth has been associated with being under 18 years of age having had an episode of homelessness in the last six months and the use of heroin or cocaine 3 about onethird to one half of all homeless youth exchange sex for money drugs food or a place to stay 27 while drug use among homeless men has been associated with having multiple sexual partners 28 however our findings are unique in quantifying the extent of sexual partners with whom youth engaged sexually german et al 7 found that among young thai women having multiple sexual partners was associated with methamphetamine use our study also showed that recent alcohol use is associated with lifetime cocaine use polysubstance use including the use of alcohol is very common among homeless youths 2930 and methamphetamine abuse has been linked to alcohol abuse among nonhomeless youths 31 however we didnt find a link between methamphetamine and alcohol we also examined the role of social support and its effect on stimulant use among our participants youths lacking social support had lower odds of reporting cocaine use compared with those who had more support the literature contains contrasting reports on the relationship of social support with drug use among young populations greater levels of social support have been found to be deterrents to drug use among homeless youth living in san diego 29 alternatively among homeless groups padgette et al 32 were not able to show that social support was associated with positive drug use reduction however programs that focus on building social support systems for homeless youth have been positively associated with drug abuse reduction 33 thus we have added additional findings to the literature in this regard moreover our findings of the negative relationship between spirituality and methamphetamine use is novel information that can be further considered as a positive factor which can be incorporated into successful intervention programs for homeless drugusing youth regarding the effect of ethnicity on stimulant use we found that africanamerican homeless youth were less likely to report cocaine use compared to their white counterparts this is consistent with findings from russell and colleagues 6 showing that caucasian youth are more likely to use methamphetamines compared with african american youth 6 the cocaine finding is also consistent with findings from an earlier study showing that africanamerican homeless youth in san diego were less likely to engage in substance abuse behaviors compared with their nonafricanamerican counterparts 29 in addition to ethnicity we found that older age was associated with methamphetamine use among our participants this finding adds new knowledge to the literature on associations of age and methamphetamine use being younger than 18 years has been identified as a predictor of idu among homeless youths living in montreal 34 in a more recent study of homeless youths living in the us younger age has also been associated with substance use 30 finally we found that persons with a history of incarceration and those who had previously been in foster care were three times more likely to use methamphetamine than counterparts without such a background the incarceration findings provide added support to the evidence to date incarceration has been associated with both cocaine and methamphetamine use among general populations 35 this study provides more specific knowledge about homeless youth in particular in a recent study of homeless youths methamphetamine use was correlated with incarceration 36 the association of methamphetamine use with foster care is also consistent with findings in a report published by the public health agency in canada in that report having ever lived in a group or foster home was associated with drug abuse among homeless youth populations 37 study limitations we used a convenience sample of participants recruited from santa monica california given the lack of random sampling our results may not be widely generalizable to other groups of homeless youths living elsewhere across the united states or even in other parts of los angeles however representative samples of homeless adults are very difficult and expensive to construct and much less is known about homeless youth this pilot study used data from a site homeless youth chose to frequent and thus may reflect characteristics of homeless youth who are willing to use informal services the fact that many of the findings are consistent with previous studies of homeless youth suggests that the sample was not atypical another study limitation is the fact that we used questionnaires based on selfreport to collect information from our participants this procedure may threaten the study validity due to social response bias however in a previous study of homeless women we found good agreement between selfreported cocaine use and objective data based on hair analysis 38 despite the limitations addressed above our study has important strengths we were able to collect information on a wide variety of variables and identify a number of characteristics of homeless youth who use cocaine and methamphetamine while other studies have examined variables associated with drug use among homeless youth our study is unique in that we were able to show that there are a number of factors which can coexist and at the same time have a potential impact on stimulant use among homeless youth it is not a surprise that having no social support recent alcohol use injection drug use and having multiple sex partners were associated with cocaine use however we need to further explore findings that being a person of faith and having a history of foster care placement were associated with methamphetamine use we are unaware of studies that identify these relationships conclusion findings from this study have important implications with respect to how our society deals with substance abuse among young homeless persons we have shown that stimulant use is a problem that often coexists with other difficulties stimulant use among exoffenders is associated with increased hiv risk behaviors 39 stimulant use also is associated with behavior necessary to support addiction ie sex trade involvement theft and other criminal activities that result in incarceration 36 in light of our findings drug abuse reduction interventions should be designed to address the multiple challenges that confront young homeless people our findings also suggest that the effect of social support among young drug users needs clarification we believe that future studies of the effect of social support will help healthcare providers ascertain how to best provide for the psychosocial needs of this very challenging population our findings indicate almost one third of the homeless youth reported a history of foster care placement research identifies the link between foster care history and homelessness 4041 the national alliance to end homelessness 42 reports over 26000 youth age out of the child welfare system annually and never reconnect permanently with their biological family youth who emancipate from foster care are at risk for negative outcomes such as homelessness poverty incarceration mental illness and substance abuse 42 scant evidence exists in the literature related to stimulant use among homeless youth and young adults with a history of foster care placement it is known however that children with a history of abuse and multiple unstable foster care placements have serious mental health disorders such as depression anxiety aggression attentiondeficithyperactivity disorder conduct disorder or posttraumatic stress disorder 43 pharmacotherapy is the mainstay of treatment for childhood mental disorders with constant clinical observation 44 homeless youth and young adults with a history of foster care placement will not have access to beneficial psychotropic medications they might seek stimulants to decrease symptoms more research is needed with this specific population of homeless individuals treatment interventions might be different compared with those for homeless youthyoung adults without this history

this crosssectional hepatitis health promotion study n 156 was designed to identify correlates of cocaine and methamphetamine use among young homeless persons living in los angeles county structured questionnaires were administered at baseline to assess sociodemographic characteristics drug history and social support unadjusted analysis showed that older age having a history of incarceration injection drug use idu 10 or more sexual partners and sex for money were associated with both cocaine and methamphetamine use logistic regression results showed that injection drug users had over 7 times greater odds of using each stimulant compared with nonusers of injection drugs those reporting at least 10 sexual partners and alcohol use in the past 6 months were more likely to use cocaine than their respective counterparts africanamericans were also less likely than whites to report cocaine use understanding of these relationships can guide interventions targeting the multiple challenges faced by this population

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background according to the substance abuse and mental health service administration 5 of pregnant women used illicit drugs in the past month 1 the 2006 national survey on drug use and health found that rates of past month drug use were similar between nonpregnant women and recent mothers 2 a study examining the prevalence of substance use among more than 7800 pregnant women enrolled in prenatal care clinics identified 9 as using illicit substances when they were screened using the 4ps plus tool a measure comprised of four questions 3 an endorsement of any of the questions is indicative of a positive screen maternal substance use raises concerns about a womans capability to adequately care for her child risk factors associated with substance abuse such as cooccuring psychiatric problems violence difficulties in interpersonal relationships limited social support unstable employment histories and medical problems raise additional concerns about parenting abilities 4 5 6 7 estimates of the percentage of substance using parents involved in the child welfare system vary but there is general consensus that such families are disproportionately represented 7 8 9 10 11 maternal substance use is associated with greater numbers of infants entering the child welfare system 12 13 14 15 when substance use during pregnancy results in child welfare involvement multiple social service systems intervene to address the familys needs there is limited information about specific services used by perinatal substance users with child welfare involvement an examination of services received and child welfare outcomes can increase understanding about how best to intervene with perinatal substance users to achieve positive child welfare outcomes the present study describes services received by women participating in the vulnerable infants program of rhode island and three child welfare outcomes 1 a closed child welfare case 2 reunification with biological mother and 3 an identified permanent placement for the infant perinatal substanceusers and services the provision of comprehensive services is widely considered to improve treatment outcomes for pregnant and parenting substanceusing women 16 17 18 women often can only engage in treatment when attention is given to pragmatic concerns such as child care and transportation 19 20 21 22 a review of 38 studies of substance abuse treatment for women found that more positive treatment outcomes were associated with the availiability of child care prenatal care mental health services a focus on womens issues womenonly admissions and comprehensive treatment 192324 in another review effective programs provided parent training and family interventions visited in the home during the pregnancy to help prepare women for parenting responsibilities and fostered collaboration among multiple agencies 25 a policy review on early detection of prenatal substance exposure concluded that child developmental outcomes could be improved when child welfare systems collaborate with treatment providers and promote therapeutic as opposed to punitive actions 26 recent research has examined substance abuse treatment services and child welfare outcomes a study investigating reunification of children whose mothers participated in the california treatment outcome project reported factors associated with reunification were mothers length of time in treatment and participation in programs that addressed larger family needs such as employment and education 9 mothers with more employment and psychiatric problems were less likely to achieve reunification an examination of substance abuse treatment and oregon statewide child welfare data reported reunification was more likely when parents obtained services soon after their child was placed outofhome spent more time in treatment and completed at least one treatment 27 a study using illinois child welfare data identified high rates of cooccurring problems among substanceusing mothers and found that these problems which included mental health parenting and employment related issues decreased the likelihood of reunification 28 there was a greater likelihood of reunification when services were matched to meet mothers identified needs a survey study of predominantly poor urban substanceusing women with child welfare involvement found service matching on counseling services was associated with less substance use and ancillary service matching was associated with client satisfaction 29 the total number of services received had the strongest impact on treatment outcomes vulnerable infants program of rhode island the vulnerable infants program of rhode island began as a demonstration grant to provide care coordination services to mothers with an open child welfare case because of drug use during pregnancy enrollment in vipri typically occurs during a mothers hospitalization following delivery when prenatal substance exposure is identified either through maternal selfreport or a positive toxicology screen a hospital social worker informs the mother about vipri and with her consent makes a referral to the program the vipri care coordinator assesses maternal and infant needs and facilitates referrals to appropriate services vipri remains involved with families until a permanent placement for the infant has been identified in some instances because of the voluntary nature of the program families may withdraw before a decision regarding permanency has been made mothers who participate in vipri have the option of participating in the rhode island family treatment drug court ri ftdc is a specialized court for perinatal substance users that provides structure and support and takes an interactive therapeutic approach that involves close monitoring and making referrals to substance abuse treatment and ancillary services vipris model of closely collaborating with social service agencies expedites parents obtaining the services and supports they need services typically arranged by vipri include substance abuse treatment mental health medical care parenting and help obtaining entitlement benefits such services are generally accepted as helpful for perinatal substance users however little is known about which services are actually utilized and their relevance to child welfare outcomes the purpose of this paper is to describe the services used by mothers who participated in vipri and the following child welfare outcomes 1 status of the child welfare case 2 reunification with biological mother and 3 an identified permanent placement for the infant to our knowledge this is the first study to describe services for perinatal substance users and child welfare outcomes methods an analysis of data from the first four years of vipri identified services used by mothers while participating in vipri and if the child welfare case had been closed if reunification had been achieved and if a permanent placement for the infant had been established the hospital institutional review board granted approval for the pilot vipri program at enrollment vipri staff administered a semistructured facetoface psychosocial history interview that included measures of maternal characteristics and information about legal invovlement substance abuse and treatment histories trauma and services received the substance abuse subtle screening inventory3 30 was used to screen for substance dependence the brief symptom inventory 31 identified mental health symptoms and the adult adolescent parenting inventory 2 32 assessed highrisk parenting attitudes each of these standardized measures has established validity and reliability information obtained from the standardized measures and the psychosocial history interview were used as the basis for identifying services mothers needed a major component of ongoing care coordination was monitoring compliance with service plans and keeping track of services vipri participants recieived over the course of their involvement in the program services were divided into eight categories shown in table 1 services were set as dichotomous yesno variables to indicate if the service was received or not the three child welfare outcomes examined were 1 a closed child welfare case 2 reunification with biological mother and 3 an identified permanent placement for the infant child welfare outcomes were obtained through court and vipri records the national perinatal information center an independent organization monitored data collection and evaluated the impact of vipri on permanency outcomes of substanceexposed infants data analysis chisquare analysis was performed comparing dichotomous variables and child welfare outcome variables descriptive results maternal demographics during the first four years 70 of mothers referred to vipri enrolled for a total of 195 mothers reasons for not enrolling were active or passive refusal ineligibility when a child welfare case was not opened after the initial cps investigation and not being appropriate for reasons that included current incarceration planning to place the child for adoption psychiatric issues not substance abuse being identified as the primary problem most participants in vipri were caucasian followed by african american hispanic and other primary drugs of choice were cocaine opiates marijuana and alcohol maternal ages ranged from 17 to 43 years at the time of enrollment in vipri 89 of the mothers were single and had an average of three children over one third of the sample had less than a high school education 61 had a high school diploma or equivalent and 2 had a fouryear college degree most mothers had no reliable source of income or received disability or entitlement benefits only 6 were employed a higher proportion of mothers with at least a high school education fewer children or only one child had closed child welfare cases maternal characteristics associated with having an open child welfare case were childhood physical abuse and a history of criminal conviction similar results were found when maternal characteristics and reunification outcomes were analyzed a greater proportion of mothers with fewer children or only one child achieved reunification a smaller proportion of mothers with less than a high school education were reunified with their children a smaller proportion of mothers with a history of childhood physical abuse achieved reunification with their infants at the time of hospital discharge 32 of infants remained with biological parents 32 were placed in kinship care 32 were placed in nonrelative foster care and 4 went to specilaized care infant placements at the time of discharge from vipri were 56 living with biological parents 22 in kindship care and 22 in nonrelative foster care there were no statistically significant associations between maternal characteristics and child welfare outcome measures and maternal race income or age there also were no statistically significant associations between maternal characteristics and infant permanent placements findings related to child welfare closed child welfare cases as shown in table 2 hiv prepost test counseling prenatal and postnatal care primary medical care family planning entitlement assistance and donations of food and clothing were the services associated with a greater percentage of closed child welfare cases reunification as shown in table 3 hiv prepost test counseling primary medical care family planning entitlement assistance and donations of food and clothing and recovery support services were associated with a greater percentage of reunification with the biological mother residential drug treatment and permanency services were less likely to be associated with reunification with the biological mother permanent placement as shown in table 4 hiv prepost test counseling and recovery support services were associated with a greater proportion of infants with permanent placements discussion families with parental substance use and child welfare involvement are less likely to reunify and more likely to experience lengthy stays in foster care and higher rates of rereporting 27 33 34 35 36 increasing our understanding of which services are associated with better child welfare outcomes has applicability to the child welfare system court treatment providers and to families results of this study can be used to generate hypotheses about how to prioritize services in a time of diminishing resources in this study the majority of services related to closed child welfare cases and reunification with biological mother were medical and financial services medical services included hiv prepost test counseling prenatal and postnatal care primary medical care and family planning medical professionals should be aware of the positive impact they can have on the lives of substanceexposed infants and parents beyond the medical attention they provide a strong connection with medical providers can serve families well in terms of following through with routine medical visits and providing a foundation of care for a mother to address concerns about her own and her childrens health financial services that were associated with positive child welfare outcomes included assistance with entitlement benefits and obtaining food and clothing stress associated with not having essential needs met can interfere with a womans ability to focus on treatment and may contribute to her questioning if she is able to adequately provide for her children ensuring that a familys basic needs are met may have the additional benefits of promoting a mothers ability to work on recovery and child welfare case plans by allaying worries about how to feed clothe and shelter her children building in these services as part of child welfare treatment or court may contribute to more positive child welfare outcomes not all services were associated with favorable child welfare outcomes permanency services and residential drug treatment were less likely to be associated with reunification with the biological mother or identified permanent placements for infants permanency services included providing support to families who were voluntarily or involuntarily having parental rights terminated which may account for these services being associated with infants not being reunified or having established permanent placements residential treatment may have been a marker for more severe addiction and related risk factors which may have indicated a poorer prognosis study limitations involvement in child welfare because of drug use during pregnancy is a complicated issue and numerous factors affect child welfare outcomes this study did not control for other factors that could have influenced child welfare outcome such as social support networks satisfaction with services etc this study did not correct for multiple comparisons because the purpose of the study was to describe services related to specific outcomes as this had not been done previously adjustment for multiple comparisons protects against rejecting the null hypothesis when it is correct however the cost of this protection is to increase type ii error that findings are attributable to chance when they are not in addition this study is limited to a population of perinatal substance users who participated in an innovative program vipri which has an active partnership with the states ftdc there was no comparison group of mothers with open child welfare cases because of drug use during pregnancy who did not participate in vipri conclusion services that addressed family health and financial needs were associated with favorable child welfare outcomes for perinatal substance users with child welfare involvement when considering the range of services substanceusing women often need it is important to make sure that their basic needs are not overlooked alleviating health and financial pressures may have positive consequences for women struggling to address substance abuse while attempting to assume parenting responsibilities by allowing them to focus more on their recovery and parenting skills as they attempt to succeed with their child welfare case plans author details 1 regional child protection center blank childrens hospital des moines ia 50309 usa 2 brown center for the study of children at risk women infants hospital providence ri usa 3 brown alpert medical school providence ri usa 4 national perinatal information center providence ri usa 5 department of psychology community college of rhode island warwick ri usa authors contributions kjm jet bml conceived of the study and wrote the manuscript dc performed the statistical analysis rs la coordinated vipri and the collection of data all authors have read and approved the final manuscript competing interests the authors declare that they have no competing interests

background substance use during pregnancy often leads to involvement in the child welfare system resulting in multiple social service systems and service providers working with families to achieve successful child welfare outcomes the vulnerable infants program of rhode island vipri is a care coordination program developed to work with perinatal substanceusers to optimize opportunities for reunification and promote permanency for substanceexposed infants this paper describes services used by vipri participants and child welfare outcomes methods data collected during the first four years of vipri were used to identify characteristics of program participants services received and child welfare outcomes closed child welfare cases reunification with biological mothers and identified infant permanent placements descriptive results medical and financial services were associated with positive child welfare outcomes medical services included family planning preand postnatal care and hiv test counseling financial services included assistance with obtaining entitlement benefits and receiving tangible support such as food and clothing conclusions findings from this study suggest services that address basic family needs were related to positive child welfare outcomes the provision of basic services such as health care and financial assistance through entitlement benefits and tangible donations may help to establish a foundation so mothers can concentrate on recovery and parenting skills identification of services for perinatal substance users that are associated with more successful child welfare outcomes has implications for the child welfare system treatment providers courts and families

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introduction in april 2016 the government of lesothos ministry of health released new guidelines on the use of antiretroviral therapy for hiv prevention and treatment these guidelines introduced oral preexposure prophylaxis as part of the national hiv prevention strategy 1 prep refers to the use of antiretroviral drugs in hivnegative people to reduce their risk of acquiring hiv infection a combination of two hiv medicines sold under the name truvada is approved for daily use as prep studies have shown that prep is highly effective at preventing hiv if it is used as prescribed 2 3 4 5 prep alone helps reduce the risk of hiv infection in the absence of other prevention methods such as condoms the risk of getting hiv from sex is further reduced if prep is used in combination with condoms or other prevention methods however prep is much less effective when it is not taken consistently on a daily basis 6 the 2016 moh guidelines include recommendations for healthcare providers to determine the eligibility of subjects who may benefit from prep a risk assessment should be conducted for hivnegative individuals and should inquire about known highrisk behaviors that increase ones likelihood of acquiring hiv nevertheless although an individual risk assessment is always recommended the moh guidelines list key populations to whom prep services should be particularly targeted these include those who have exchanged sex for money or paid for sex men who have sex with men and transgender individuals people who inject drugs people in serodiscordant relationships where the hivpositive partner is not on art those in serodiscordant relationships where the hivpositive partner has been on art for less than 12 months those in serodiscordant relationships where the hivpositive partners viral load is 1000 copiesml or recent viral load is not known but partners art adherence is documented to be poor those with multiple concurrent sexual partners and incarcerated individuals additionally intimate partner violence is identified as one of the main drivers of the hiv epidemic in lesotho in the 2016 ministry of health hiv testing guidelines however people who experience ipv are not explicitly mentioned among the key populations to whom prep should be targeted across all populations young women aged 1529 are among those with the highest estimated hiv incidence in lesotho equal to 19 new infections per 100 personyears of exposure 7 multiple factors have been associated with the increased hiv incidence in this population either because they experience genderbased inequality or because they lack economic empowerment young women may exchange sex for money or economic support and thus meet the definition of highrisk population to whom prep provision should be targeted in addition to this young women being less likely to be married may have multiple concurrent sexual partners and therefore be eligible for targeted prep service provision as per 2016 moh guidelines furthermore young women who exchange sex for money or economic support experience gender power imbalance which may translate into other forms of coercion and abuse the association between transactional sex and intimate partner violence has been long established 89 for instance wood and jewkes 8 found that women who engage in transactional sex with men are more likely to experience ipv women may feel forced to remain in these relationships if the partner provides critical income there is a demonstrated association between transactional sex and incidence of hiv infection 1011 power imbalance in sexual interactions has also been previously described as a barrier to condom use negotiation 12 as for multiple concurrent sexual partnerships mixed evidence has been reported on the role of the network effect in the hiv epidemic 13 14 15 nevertheless multiple concurrent sexual partnerships have been associated with an increased risk of hiv infection in endemic areas by several researchers both in mathematical model studies 16 and comparative studies of sexual behavior 1718 this research informed the inclusion of those who have exchanged sex for money and those with multiple concurrent sexual partners in the 2016 guidelines listing key populations to whom prep service provision should be targeted a combination of these factors may affect young women and contribute to the observed increased incidence among this key population it is therefore important to understand to what extent do these factors translate into actual hiv risk selfperception and willingness to use prep in particular female university students may face several of the potential risk factors that affect the broader womens population which are included in the moh hiv testing and prep guidelines they are part of the age and gender group with the highest estimated incidence they may face genderbased violence and ipv they may engage in transactional sex because they lack economic stability and may as well have multiple concurrent sexual partners because due to their younger age they are less likely to be married than their older peers it is of public health interest to understand whether female university students who meet the moh criteria for prep targeting would be willing to use prep it is also important to understand whether there exist other determinants for willingness to use prep in this population finally because prep use may be influenced among other factors by ones hiv risk selfperception it is important to identify what are the factors that more than others affect womens hiv risk selfperception and to what extent does this latter translate into interest in using prep therefore the purpose of this study is to assess hiv risk perception and willingness to use prep as well as their associations to condom use and negotiation exposure to ipv sexual coercion and other risk factors among a subpopulation of young women in lesotho representative of those attending tertiary education institutions in order to inform hiv prevention strategies and future operational research on integrated service provision in lesotho methods measures data on demographic characteristics hiv risk factorsand risk perception condom use and condom negotiation genderbased violence indicators and willingness to use prep were collected using selfadministered questionnaires peer networks have been reported to influence mens perpetration of ipv through the internalization of peer network norms the pressure to conform to peer network norms and the direct involvement of peers in shaping couple power dynamics 19 indirect questioning to estimate intimate partner violence in population surveys has been validated by previous studies 2021 therefore to deal with the information bias that may be generated by selfreporting on intimate partner violence we used intimate partner violence in the respondents network of peers as a proxy to estimate womens experience of intimate partner violence we used the question were any of your friends hit or beaten by their boyfriends or husbands and coded the answers in a binary yes or no variable with a third choice to capture dont know answers in addition to ipv sexual exploitation and abuse is another form of genderbased violence to capture this information we asked participants whether they had ever had sex for money and whether to their knowledge any of their peers had responses were captured as binary variables taking the values of yes or no with an additional option coding dont know answers furthermore we asked participants whether they had ever been forced to have sex answers to the question how many times have you been forced or pushed to have sex against your will were recoded into a binary variable taking a value of 1 in the presence of any occurrence and 0 otherwise to elicit information about respondents sexual networks characteristics we asked whether they currently had a sexual partner and whether they currently had one or multiple partners furthermore we asked whether the respondents main partner was in an monogamous relationship with the respondent or not based on the fact that customary law allows polygamy in lesotho imperfect condom use was defined using the question in the last 6 months how often did you use condoms when you had sex and was encoded with a value of 0 if the selected answer was always and with a value of 1 if the answer was any among the prompted options most of the times sometimes rarely or never negative attitude towards condom use was captured by asking the following question to what extent do you agree with the following statement i do not like condoms and recoding the answer as 1 if the respondent answered agree or strongly agree additionally information on condom negotiation was elicited by asking in your experience how hard is it to negotiate condom use with men and recoded as 1 if the respondent answered hard or very hard finally stis history was elicited by asking have you had any stis or issues regarding your sexual and reproductive health in the last twelve months and answers were coded as positive if the respondent answered that yes she had an sti in the past 12 months or that she was not sure about it to capture information on antibiotic adherence answers to the question when i had to take antibiotics or other medications it was easy for me to remember to take the daily dose were recoded to 1 if the answer to the question was strongly agree and recoded to 0 if the respondent answered agree disagree strongly disagree or dont know this conservative approach was used to identify those respondents that reported the highest level of adherence to daily medications considering that prep efficacy is maintained by taking it consistently on a daily basis to assess hiv risk perception a potential mediator in the causal pathway for willingness to use prep the question how likely do you think it is that you will get hiv was measured on a threepoint scale with the options very likely somewhat likely and not likely with additional options for i already have hiv and dont know analyses were conducted by converting it into a binary measure obtained by merging the first two option choices finally to assess the outcome of interest willingness to use prep we used the question to what extent do you agree with the following statement if prep was available in my community i would probably take it the response options were strongly agree agree disagree strongly disagree and dont know because we wanted our measure to reflect as closely as possible the real anticipated intentions of participants with respect to prep utilization and assuming that a moderate interest is less likely to translate into actual utilization than a strong interest we converted the variable willingness to use prep into a binary form where only those who answered strongly agree were assigned a value of 1 and all others a value of 0 analytical methods first we performed bivariate analyses with pearson χ2 tests on categorical variables to compare participants who perceived themselves at risk of hiv to those who did not perceive to be at risk and those who expressed strong willingness to use prep to those who did not additionally we performed a multivariate mediation analysis where hiv risk perception is the mediator and willingness to use prep is the final outcome of interest to estimate the mediation model we drew from baron and kenny 22 methodology first we ran a model with hiv risk perception as the outcome and then we ran a model with willingness to use prep as the outcome including also hiv risk perception and all the other covariates the multivariate mediation analysis was conducted using linear probability model regressions with 500 bootstrap repetitions to construct biascorrected confidence intervals a simplified description of the relation under investigation is depicted in the directed acyclic graph in fig 1 individual characteristics or covariates are individuallevel exposures that may affect hiv risk selfperception which in turn is hypothesized to act as a mediator and influence ones willingness to use prep furthermore individuallevel exposures may as well have a direct effect on willingness to use prep we hypothesize that while some covariates affect willingness to use prep exclusively via the indirect mediated pathway other variables may directly shift ones willingness to use prep without being mediated by hiv risk perception in all analyses and tables pvalue significance levels of 90 and 99 were reported together with the reference significance value of 95 ethics statement ethical approval for this study was obtained from the office of human research administration at harvard longwood medical area under irb protocol 160891 the clinton health access initiative scientific and ethical review committee and the lesotho ministry of health ethics and research committee under the protocol id942016 the corresponding author was employed at chai during survey design and data collection phases results participants averaged 2182 years of age of all participants 118 had more than one concurrent sexual partner at the time of the interview and 85 reported having friends who had sex for money 113 reported finding it hard to negotiate condom use 129 reported having friends that were beaten by male partners and 118 reported having been forced to have sex against their will at least once tertiary education institution where the interviews took place were mainly located in the university city roma the capital city maseru as well as in other districts of lesotho overall 573 of the sample perceived themselves at risk of acquiring hiv in bivariate analyses perceived hiv risk was strongly associated with a history of sexually transmitted infections with experiences of sexual coercion and with sexual partners in polygamous relationships perceived hiv risk was also significantly associated with difficulty in negotiating condom use ipv in the network of peers inconsistent condom use and multiple concurrent sexual partnerships of all the respondents 321 reported to be strongly willing to use prep if it were available in their community willingness to use prep was strongly associated with perceived hiv risk reported strong adherence to antibiotics negative attitude towards condom use ipv in the network of peers and experiences of transactional sex in the network of peers willingness to use prep was also significantly associated with having sexual partners in polygamous relationships a multivariate mediation analysis was conducted using the same covariates included in the bivariate analyses and controlling also for age and institution table 3 presents the results of each part of the mediation pathway separately by showing the indirect effects of the covariates on the mediator and the effect of the mediator on the outcome and jointly by reporting the biascorrected bootstrap confidence interval as hypothesized perceived hiv risk was found to be a significant mediator being associated with 115 percentage points increase in likelihood of using prep three covariates showed a significant mediated indirect pathway for willingness to use prep multiple concurrent sexual partnership was associated with 161 percentage points increase in likelihood of selfperceived hiv risk while having sexual partners in polygamous relationships was associated with 178 percentage points increase in likelihood of selfperceived hiv risk and the mediated indirect effect accounted for 182 of its total effect similarly history of sexually transmitted infections was also found to be statistically significant and associated with 165 percentage points increase in likelihood of selfperceived hiv risk having experienced sexual coercion only approached significance at 95 confidence level as expected some covariates were directly associated with willingness to use prep and their effect was not mediated by hiv risk perception those who reported strong adherence to antibiotics were 231 percentage points more likely to express willingness to use prep than those who did not and those who reported to dislike condoms were 191 percentage points more likely to be willing to use prep than those who did not report aversion to condom use interestingly ipv in the network of peers was also directly associated with willingness to use prep and its effect was not significantly mediated by hiv risk perception those who had friends who experienced intimate partner violence were 149 percentage points more likely to be willing to use prep than those who did not report ipv in their network of peers discussion this study on willingness to use prep among female university students in lesotho was prompted by the introduction in april 2016 of new ministerial guidelines on the use of antiretroviral therapy for hiv prevention and treatment which introduced oral prep as a new hiv prevention service for highrisk individuals in lesotho the study focused on young women because they had been previously identified as one of the populations with the highest hiv incidence in the country and because they may experience intimate partner violence engage in transactional sex and have multiple concurrent sexual partnerships which have been previously associated with increased likelihood of hiv infection in particular the study focused on women attending tertiary education institutions in lesotho at the time of the survey in this sample of 302 female university students more than half considered themselves very likely or somewhat likely to acquire hiv and one in three reported strong intentions to use prep if it were available in their community a multivariate mediation analysis indicated that multiple concurrent sexual partnerships and having a partner in polygamous relationships had independent associations with perceived hiv risk and perceived hiv risk significantly mediated their effect on willingness to use prep as expected then hiv risk perception did not mediate the effect of reporting strong adherence to antibiotics and reporting negative attitudes towards condom use on willingness to use prep these two factors affect the likelihood of prep uptake independently from perceived hiv risk importantly ipv in the network of peers was strongly associated with increased willingness to use prep and hiv risk perception did not significantly mediated this effect this seems to confirm that ipv in peer networks may relate to ones individual risk perception through direct involvement of peers in shaping couple power dynamics as previously suggested or because similar baseline characteristics act as cofactors in determining relationships and forming networks in both cases these hypotheses support the conclusion that findings that relate to women who experience ipv in their network of peers may as well apply to women who directly experience ipv indirectly these findings also suggest that women who are part of networks where ipv is common feel more at risk of acquiring hiv 23 24 25 although they may not consider such risk to be necessarily imminent or current another possible explanation to the fact that ipv in the network of peers had a direct effect on willingness to use prep not mediated by hiv risk perception is that women who witness ipv in their peers network may not feel directly at risk of contracting hiv but would nevertheless prefer to be protected perhaps because their exposure to ipv dynamics has made them more aware and therefore less prone to risk taking the findings of this study have significant implications for hiv prevention programs in lesotho first they strongly suggest that moh prep guidelines be reviewed to include women who experience ipv among the key populations to whom prep should be targeted this would also ensure consistency between prep guidelines and hiv testing guidelines where this key population is identified as one among those at higher risk the results of this study seem to support the use of indirect questioning to elicit information about ipv and suggest that ipv in their network of peers may actually translate into increased will for hiv prevention second women in multiple concurrent sexual partnerships perceive themselves at higher risk of acquiring hiv which supports the inclusion of individuals with multiple concurrent sexual partners among the categories to whom prep service provision should be targeted based on the 2016 ministerial guidelines nevertheless an objective assessment of individuals risk behavior is always recommended because an individuals selfperception of hiv risk may not coincide with ones objective risk of hiv third there exist predictors of prep uptake that do not depend on hiv risk perception and these include adherence to daily medications and negative attitudes towards condoms women who expressed a negative attitude towards condom use are significantly more willing to use prep than their peers suggesting that this subpopulation may be likely to use prep in lieu of condoms regardless of their perceived risk of contracting hiv based on these findings condom use should be particularly encouraged and monitored while scaling up prep in similar populations that present high degree of aversion to condom use finally strong selfreported adherence to daily antibiotics is a significant independent predictor of anticipated prep uptake confirming adherence as one of the possible barriers to prep utilization 26 hiv risk perception is a significant predictor of willingness to use prep however similarly to previous studies 27 willingness to use prep is not always driven by higher hiv risk selfperception since several women in the sample who did not feel at particular risk of contracting hiv showed interest in this preventive measure this apparent contradiction may be explained by higher risk aversion as well as by the fact that certain individual characteristics such as adversity to condom use constitute by themselves strong predictors of prep uptake regardless of current hiv risk selfperception future campaigns to expand prep utilization should therefore focus as well on factors that are not necessarily linked to ones hiv risk selfperception this study had several limitations one limitation is that the survey was only conducted with university students which is a subgroup that may not be generalizable to the larger population of adolescent girls and young women in lesotho furthermore the participants were concentrated in the capital city maseru and the university city roma which limits the extent to which one can extrapolate to more rural populations however since the hiv burden is highest in the urban center of maseru focusing on this population does make sense in developing an hiv prevention strategy for the country yet more research on less educated and more rural populations may be warranted in the development of a comprehensive hiv prevention and prep strategy for adolescent girls and young women in lesotho one other limitation of the study is that the data is all selfreported especially since the study is dealing with sensitive issues regarding sexual behavior respondents may have felt a social pressure to answer questions in a certain way while attention was taken in the wording of questions as to not bias participants and participants were able to complete the survey in private there remains a risk of social desirability bias or respondents not understanding the questions it also must be acknowledged that we were asking questions about future behavior which is very difficult to do given that participants have a hard time projecting attitudes and behavior to the future this study is the first of its kind in lesotho to examine hiv risk perception and its relation to hiv risk factors ipv predictors and their association with anticipated uptake of prep among female university students followup research should be conducted to examine actual utilization of prep among female university students in lesotho and understand whether this aligns with anticipated intentions of use all files are available at the link agywpreplesotho s2 table

oral preexposure prophylaxis prep for hivnegative individuals at high risk was introduced in lesotho in april 2016 to assess the feasibility and acceptability of prep in lesotho and to study the attitudes and beliefs around hiv risk and prevention measures among young women between september and december 2016 we asked 302 female university students at fourteen higher education institutions in lesotho about their sexual behavior experiences of sexual coercion and abuse hiv risk perception willingness to use prep as well as their attitudes toward condom use and selfadministration of daily medications overall 573 of the sample reported perceiving themselves at risk of acquiring hiv and 321 reported being strongly willing to use prep if it were available in their community in a multivariate mediation analysis perceived hiv risk was associated with 115 percentage points increase in likelihood of using prep p 0041 multiple concurrent sexual partnership was associated with 161 percentage points increase in likelihood of selfperceived hiv risk p 0007 while having sexual partners in polygamous relationships was associated with 178 percentage points increase in likelihood of selfperceived hiv risk p 0002 and the mediated indirect effect accounted for 182 of its total effect those who reported strong adherence to antibiotics were 231 percentage points more likely to express willingness to use prep than those who did not p 0004 and those who reported to dislike condoms were 191 percentage points more likely to be willing to use prep than those who did not report aversion to condom use these effect were direct and not mediated by hiv risk perception intimate partner violence ipv in the network of peers was also directly associated with willingness to use prep and its effect was not significantly mediated by hiv risk perception those who had friends who experienced intimate partner violence were 149 percentage points more likely to be willing to use prep than those who did not report ipv in their network of peers p 0009 these findings support the inclusion of individuals with multiple concurrent sexual partners among the key populations for prep provision and confirm that willingness to use prep is not solely driven by hiv risk perception they also indicate that the presence of ipv in peer networks is related to ones willingness to use prep prep service provision may generate synergies with ipv prevention programs when offered within this framework

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background recognition of the role of structural cultural political and social determinants of health is increasing 1 2 3 4 5 particularly for first nations australians 1 78 despite this the comparative health and wellbeing of first nations australians is significantly lower than that of other australians 9 10 11 previous studies have described key elements needed to improve first nations australians health and wellbeing these include recognition and removal of historical and ongoing colonization dispossession exclusion and discrimination and the promotion of first nations australianled decisionmaking 12 13 14 the principle of selfdetermination which was identified and recognized by the united nations in the years after the second world war includes recognition of the right to determine ones own political status and to pursue social economic and cultural development 15 this is consistent with the collective right of selfdetermination in the universal declaration of human rights 16 however by construct indigenous peoples were excluded from such rights until the 1960s 17 following decades of advocacy the 2007 un declaration on the rights of indigenous peoples acknowledged the vital importance of selfdetermination 18 19 20 21 22 23 australia initially opposed the undrip but became a signatory in 2009 with some caveats 2 1518 23 24 25 selfdetermination is the cornerstone needed to address the historical and ongoing trauma of colonization experienced by indigenous peoples including first nations australians 71426 there are also many layers to selfdetermination including both personal and community empowerment while it is complex challenging to define and means different things to different people in varying contexts 27 28 29 30 we define selfdetermination as … the internationally recognised and ongoing right of indigenous peoples to collectively determine their own pathway within and outside of existing settler societies 15 the absence of treaties between australian governments and first nations australians 31 has led to the operationalization of selfdetermination to some extent via government policy 3233 this is in contrast to other former british colonies such as aotearoanew zealand where the tiriti o waitangi is a constitutional document 34 for example from the 1970s to mid1990s selfdetermination or selfmanagement by first nations australians was an australian government policy 33 a key feature of this legislation was the nationally representative aboriginal and torres strait islander commission atsic was created as a first nations australianled body of communityelected representatives 3536 that was embedded in legislation at a federal level 37 its purpose was for first nations australians to have input into policy development and funding decisions 38 atsic was disbanded in 2005 despite recommendations for it to continue 39 following a change in australian government leadership by then prime minister john howard 3240 since then various advisory committees with governmentappointed membership have filled some aspects of the roles of atsic 4142 first nations australian communities have a strong history of leading responses to reduce alcohol socialand healthrelated harms examples include supply reduction 4546 harm reduction 47 48 49 50 and demand reduction 51 52 53 54 community ownership and leadership have been identified as integral to the success of these initiatives 55 56 57 58 a critical point is that simply including first nations australians in policy development does not equate to selfdetermination 305960 however while the right to selfdetermination in the development of policy including that related to health and alcohol affecting first nations australians is necessary 6061 we were unable to find studies that demonstrated how selfdetermination could be achieved in this setting 15 to address this knowledge gap this study aims to identify expert opinion on what is needed for first nations australians selfdetermination in the development of healthand alcoholrelated policy 2 australia objected to the undrip on the grounds of two articles requiring indigenous peoples consent in the development of policy and use of land and resources 1518 23 24 25 3 dry areas are areas where the public consumption and sometimes possession of alcohol is not permitted 4344 4 accords are locally negotiated agreements between the retailers and community regarding the sale and availability of alcohol 43 5 night patrols are first nations australian communityinitiated groups that travel around the local community with the primary purpose of reducing alcoholrelated social harms 4748 6 soberingup shelters are facilities where intoxicated individuals are diverted from police lockups and public spaces to a safe place where they can recover while they may be encouraged to seek further assistance once sober the primary purpose is to focus on immediate safety 4950 1 first nations australians has been used to collectively refer to all the peoples within australia also known as indigenous aboriginal and torres strait islander this phrase has been used with consideration and recognition of the diversity of nations peoples and cultures that continue to live and care for the lands now referred to as australia the islands of the torres strait and the waters surrounding them 6 e methods study design the delphi technique is a multistage iterative survey approach that uses a panel of experts to translate individual opinions into group consensus 62 63 64 65 a key feature is that delphi allows for diverse perspectives and views 66 which is an essential feature in a study about selfdetermination especially where there is a dearth of formal research reports 67 a series of webbased surveys 6568 were used to ensure participant anonymity 69 individual perspectives without influence of other panellists 70 controlled feedback of findings between survey rounds 62 national contributions without the need for interstate travel 71 and flexible nononerous participation to suit each panellist 72 73 74 it should be noted that this study was developed within the context of the covid19 pandemic when travel between states territories in australia was restricted to only essential travel until november 2020 71 formation of the panel selection criteria for the panel were as follows age 18 years at least 5 years of professional experience in the health andor alcohol and other drug sectors and professional involvement in development of policy related to health and alcohol no definitive number of experts are required for a delphi study with variation based on the scope of the study and available resources 6275 we aimed to recruit a diverse panel 76 in relation to gender indigeneity region and related professional experience and qualifications perspectives were also sought from nonindigenous peoples with experience in developing evaluating andor advocating for alcohol interventions led by first nations australians panel recruitment all panellists were recruited using purposive sampling thirtynine experts were invited to participate by personalized email or phone call of these 31 experts had professional connections with the research team the remainder were suggested for recruitment by other panellists even though objectivity is important research with first nations australian communities requires interaction and accountability between the researchers and participants 737778 ethics ethical approval was provided by the curtin university human research ethics committee and the central australian human research ethics committee participation was optin and voluntary informed consent was sought electronically prior to the commencement of each survey procedure data collection data were collected using an electronic survey across three sequential rounds in september october and december 2020 inspired by the classic delphi approach 6276 the purpose of round 1 was to gain panellists views and perspectives primarily via openended qualitative questions rounds 2 and 3 used structured questions with opentext fields for panellists to expand on responses when appropriate continuous or categorical likert scales were used for ranking of response options 79 each survey was tested prior to distribution for usability and timeliness by members of the research team and by first nations and nonindigenous australians not involved in the study after survey finalization a personal survey link was sent to each participant responses were analysed after each round and a plain english summary was then emailed to panellists along with the next survey survey links were active for 3 weeks with up to four personalized reminders given usually by aes panellists were also given the opportunity to complete the surveys by videoconference or phone interview at the completion of round 3 panellists received a gift card to acknowledge their contribution to the study round 1 survey in round 1 the survey consisted of four sections demographics essential elements needed for the policy development processes to be described as involving selfdetermination degree of selfdetermination in examples of policy development processes and the type of representation and methods needed to be inclusive of first nations australians and essential stages for first nations australians to be included in policy development and suggested examples round 2 survey in round 2 the survey aimed to seek consensus on seven questions derived from round 1 analysis q1q2 macrolevel 7 conditions and values table 1 summary of surveys by round a round 1the number of questions for the section round 2 and round 3the number of elements for each question arising from analysis of round 1 and round 2 survey data b see table 2 c 110 continuous likert scale 1 not selfdetermination to 10 definitely selfdetermination d eight options not at all agendasetting stage consultation policy creation implementation monitoring evaluation all stages e fouroption likert nonnegotiable and can be implemented now nonnegotiable but is aspirational and unlikely at present ideal but not necessary not selfdetermination f 17 continuous likert scale 1 not selfdetermination to 7 nonnegotiable necessary for selfdetermination g threeoption likert always include include in some contexts but not all inclusion is not selfdetermination h four options type of representation stage that first nations australians were involved how first nations australians were involved and aim of the example provided questions response round 3 survey in round 3 we sought consensus on six questions and related elements that did not reach consensus in round 2 questions focused on the following structural changes at a federal government level deemed necessary for first nations australians selfdetermination in policy development processes essentials for selfdetermination to be part of policy development processes types of representation needed and implementation round 3 also included elements suggested by panellists q5 and q7 were asked again with response categories amended based on panellists feedback data analysis all survey data were collected using qualtrics 80 a webbased survey platform qualitative data were analysed using content analysis 81 textbased responses were reviewed and thematically analysed 82 coding was reviewed by another author responses were grouped into similar themes which became round 2 questions with the subthemes being elements that were ranked within each question additional checking from a third author ensured that data were appropriately categorized consensus level was set at 80 agreement in panellists rankings 7683 in rounds 2 and 3 the sevenpoint continuous likert scales were collapsed into three categories in round 2 the categorical responses for q1 and q2 were collapsed into three groups results panel of experts twenty individuals from six australian states or territories 8 participated in at least one survey round the majority of panellists completed two or more survey rounds with 60 completing all three rounds despite reaching a first nations australian majority prior to commencement four experts withdrew and did not participate in any surveys the time of the year and competing priorities were the main reasons reported by panellists for survey noncompletion one panellist preferred to complete rounds 2 and 3 via phone just over half of the panellists were in academic roles with more than 200 years of combined experience the remaining panellists were either executive officers or senior programarea managers with more than 170 years of combined professional experience in first nations australian communityled organizations and more than 100 years of experience on national or state advisory committees round 1 seventeen panellists completed the round 1 survey six main themes and 60 related subthemes were identified the themes were multilayered recognizing that changes at a macro through to micro 9 level were needed to develop and implement policy with first nations australian communities panellists identified that first nations australians selfdetermination in policy development requires considerations in the following areas support from the federal government at a macro level values underpinning the entire process specific elements essential to the entire policy process decisionmaking within the policy development process first nations australian representation and essential elements for implementation in addition panellists suggested 10 examples of first nations australians selfdetermination in policy development processes six of which were included as reallife vignettes types of first nations australian representation in policy processes no elements reached more than 80 agreement when ranking types of representation one element was ranked by all panellists as being definitely or possibly selfdetermination of the remaining elements involvement as stakeholders was ranked by just over one third of panellists as definitely not selfdetermination ways of including first nations australians in policy processes ways that first nations australians can be included in policy development processes did not reach consensus three elements were ranked by all panellists as being possibly or definitely selfdetermination first nations australiandefined approach first nations australiandefined representative bodygroup and first nations australianled lobbying at the other end of the scale two elements were ranked as not selfdetermination general consultation and policy that is developed via a specific representative body given this lack of consensus it was clear that the elements being ranked were specific to particular processes and many were already integrated in the round questions thus this question was excluded from subsequent rounds stages of first nations australian inclusion in policy processes all panellists had directly seen or been involved in policy processes where first nations australians were included through consultation just four in 10 panellists had directly seen change across the wider government and policy systems is needed to address and remove the structural determinants of health a q2 there were a number of values identified that should underpin policy development processes for it to be seen as selfdetermination 80100 support the human rights of first nations australians are meaningfully considered the human rights of first nations australians are protected first nations australian culture and decisionmaking processes are evident throughout the process the process is informed by the priorities and needs of first nations australian communityies that are affectedimpacted the diversity of first nations australians is recognized and accepted there is improvement of first nations australian individuals and communities lives the process is driven and directed by first nations australian leadership and governance first nations australians have significant influence and power over the process q3 selfdetermination in alcohol policy requires the policymakers to use processes that ensure first nations australians… or been involved in processes that included first nations australians at all stages panellists had witnessed or been involved in policy processes that included first nations australians in 4765 of the remaining stages two panellists had seen or been involved in policy processes that had not included first nations australians at all all but one panellist said that first nations australians should be included in all stages of the policy development process the one dissenting panellist asserted that monitoring and evaluation of policy should be independent rounds 2 and 3 in round 2 panellists agreed on more than two thirds of the elements needed for first nations australians selfdetermination to be evidenced in policy development 3 these are detailed below an additional five elements were suggested for ranking in round 3 in round 3 an additional three elements reached consensus excluding q5 between 54 and 100 of elements reached consensus in each question little agreement was reached on the considerations for selfdetermination in the reallife vignettes provided q1 and q2 macrolevel conditions and values needed in the policy development process in round 2 there was almost universal agreement in the ranking of both the macrolevel conditions necessary for selfdetermination and the underlying values that should be in place in policy development processes one elementrecognition and support for the role of aboriginal communitycontrolled organizations to ensure a first nations australian voicewas ranked nonnegotiable and can be implemented now by 89 of panellists all other statements in q1 and q2 were ranked by the majority of panellists as either nonnegotiable and can be implemented now or nonnegotiable but is aspirational despite not reaching consensus in round 2 nearly nine in 10 panellists agreed in round 3 that change across the wider government and policy systems to address and remove the structural determinants of health is required to ensure first nations australians selfdetermination in policy development processes the detailed results are available see additional files 1 2 and 3 q3 essentials in the process of developing policy the majority of essential elements necessary for selfdetermination in the process of developing policy reached agreement in round 2 three quarters of elements reached consensus and an additional two elements were proposed in round 3 consensus was achieved in the ranking of nearly eight in 10 elements of these all were ranked as definitely needed for selfdetermination two elements had 100 agreement receive feedback promptly and in a suitable format and given adequate time for decisionmaking in round 3 elements that did not reach consensus were all ranked as definitely needed by half to three quarters of panellists the detailed results are available see additional files 1 and 4 q4 decisionmaking processes in policy processes in round 2 consensus was reached for seven out of 10 elements regarding the nature of decisionmaking in policy development to ensure first nations australians selfdetermination in round 2 an additional three elements were suggested are not circumvented or changed at higher tiers10 of government are balanced between the evidence base and community preferences and give first nations australian communitycontrolled organizations collective veto power at all levels all elements that reached consensus were ranked as definitely necessary for selfdetermination total agreement was reached for two elements in round 3 no further agreement was reached for the remaining six elements elements that did not reach consensus were ranked as definitely needed by just under half to three quarters of panellists the detailed results are available see additional files 1 and 5 q5 representation by first nations australians in policy processes as in round 1 minimal consensus was achieved in relation to the types of first nations australian representation that is necessary for selfdetermination in policy development in round 2 just two items reached consensus panellists agreed on two types of first nations australian representation no further consensus was reached in round 3 as presented in fig 1 there were three elements where the combined rankings of definitely and possibly selfdetermination did not achieve consensus in round 3 four in 10 panellists ranked public servants inclusion as not selfdetermination q6 factors essential in the implementation of policy in round 2 panellists agreed on three quarters of the elements that were seen as being necessary in the process of policy implementation total agreement was achieved for three elements that were definitely needed for selfdetermination in round 3 the remaining elements had similar rankings to round 2 but did not exceed 76 agreement the detailed results are available see additional files 1 and 6 q7 reallife vignettes of first nations australian involvement in policy development processes in round 2 panellists ranked the degree of selfdetermination they believed was evident in six reallife vignettes consensus was achieved in one example communityled restrictions on takeaway alcohol in fitzroy crossing 8586 in round 3 panellists considered which factors were important when considering evidence of selfdetermination in the vignettes provided in three examples consensus was reached with one elementrepresentation of first nations australians in the policy development process consensus was not reached for the other elements the stage that first nations australians were involved in how first nations australians were involved and the aim of the policy discussion to our knowledge this is the first study to explore what is necessary for first nations australians to achieve selfdetermination in the development of healthand alcoholrelated policy while selfdetermination is recognized as important to improve health and wellbeing 87 88 89 how first nations australians have been supported to action it in health and alcohol policy development is limited 326090 the expert panellists identified a series of complex interrelated and interactive elements that would be needed to scaffold first nations australians selfdetermination in policy development processes three factors warrant consideration elements that would help to enable selfdetermination in policy development do not exist in isolation communityfirst or groundup approaches to policy development are integral the impact of the current australian policy context in which policies on health and alcohol would sit interrelated nature of elements needed for selfdetermination to be evident in policy development processes panellists agreed that first nations australians need to be involved in all stages of the policy process for selfdetermination to be possible the lack of consensus achieved when panellists were asked to rate six reallife examples reflects larsens 91 findings that selfdetermination in policy development may not be present across all stages for example it is possible for selfdetermination to be evident in some stages of the policy process and completely absent in others 1591 further to this the type of representation of first nations australians needs careful consideration these results indicate and support recent pleas for representation beyond experts individuals and blanket representation as these are not selfdetermination or appropriate 1559 representation was seen as involving first nations australians in all stages of policy development by all but one panellist the one dissenting panellist explained that monitoring and evaluation should be conducted independently while there is a need for independence in the monitoring and evaluation of policy the productivity commission report positions the role of first nations australians at the epicentre when evaluating policy that affects them and their communities 92 it is clear that first nations australians must be involved throughout the development of policy but representation remains contentious as the views are as diverse as the communities and peoples involved groundup policy approach panellists agreed that policy processes should be led and defined by first nations australians from the groundup however panellists suggested that this can only be achieved when community priorities and voices are placed first 285893 for this to happen relationships with first nations australian communities need to be prioritized and their diversity recognized 7 panellists agreed that with meaningful community engagement and involvement throughout the policy development process community ownership can be created 2832 as well as a policy that is directly relevant to the affected community 93 94 95 the impact of the current australian health and alcohol policy context on achieving selfdetermination while all panellists acknowledged the right to selfdetermination some saw it as a right irrespective of the current policy context in contrast other panellists took a pragmatic approach and saw selfdetermination as an aspiration in the current australian geopolitical landscape nonetheless panellists agreed that structural change 96 was required for selfdetermination to have a better chance at success for example the australian government recently endorsed and supported a regionalized consultation process to be undertaken to recognize first nations australians in the australian constitution presented with the outcome of this consultative process in may 2017the uluru statement from the heartthe prime ministers have since vetoed the request for constitutional recognition of first nations australian voices in parliament 9798 opting instead for legislativebased rights 99 another geopolitical issue worthy of consideration is how alcoholrelated policy is contextualized in contrast to other types of healthrelated policy 57 in australia efforts to develop alcoholrelated policy have been underpinned by protectionism 100 community safety 101 justice and criminalization 102103 this approach dismisses the historical and health context of alcohol consumption by first nations australians 57 it also undermines the valuable perspectives of first nations australian communitycontrolled health organizations in the development of alcoholrelated policy first nations australian communitycontrolled organizations have grown from a rich history of selfdetermination 104105 from an individual community level through to regional and stateterritory umbrella affiliates communitycontrolled organizations have longstanding systems in place to represent their local communities this would contribute unique insights to developing alcoholrelated policy within a health context 27324557 to ensure diversity of first nations australian representation communitycontrolled health organizations should be included as one source alongside a spectrum of other types of first nations australian representation 2732 limitations this study has a number of limitations that need to be considered the lack of randomness in recruitment is often cited as a major criticism of delphi studies 62106 as the panel of experts is selected by the research team however targeted recruitment of panellists with extensive knowledge and experience in a specific area of study has been shown to be a key strength of delphi studies 75 in this study care was taken to assemble a panel with specific knowledge and expertise the panels rich experience as leaders in their respective fields provided an evidencedbased opinion from which consensus was sought panellists with limited technology access or comfort may have preferred a phone or facetoface interview rather than an online survey a varied response rate was achieved across the three rounds due to panellists professional commitments and other priorities the existing relationships between the research team and panellists may also be seen as a potential source of bias the qualitative approach used in round 1 assisted in mitigating this as panellists presented a diverse range of views and perspectives and were not responding to the views of the research team while during 2020 australia managed to control the spread of covid19 the timing of this study may have influenced the choices made by panellists 71 the focus placed on selfdetermination added complexity to the study particularly during analysis most delphi studies use discrete categorical responses 107 however this study sought to preserve the varying shades of what constitutes selfdetermination and the panellists right to cast their vote on survey questions using a continuous ranking scale 108 conclusion systemic change is needed for selfdetermination by first nations australians to be evident in the development of health and alcohol policy changes are necessary at each level of government as well as in the process of developing policy in order for first nations australians selfdetermination the diversity and polarity of panellists views in this study highlight the complexities in defining selfdetermination especially within the health and alcohol policy development context closer examination of specific policies locally is needed to assess the level of selfdetermination that first nations australians have in the development of healthand alcoholrelated policies while efficient for policymakers policy development processes led by policymakers was seen by panellists as not selfdetermination as long as the processes are defined by the government first nations australians will not have selfdetermination recognition of first nations australians right tonot just a principle ofselfdetermination is vital to improve their health and wellbeing this recognition along with communityled approaches and embedding of this right within state and federal government constitutions are key and health central clinical school nhmrc centre of research excellence in indigenous health and alcohol the university of sydney sydney new south wales australia 4 the edith collins centre sydney local health district sydney new south wales australia 5 burnet institute melbourne victoria australia 6 centre for alcohol policy research la trobe university melbourne victoria australia 7 national drug and alcohol research centre university of new south wales sydney new south wales australia 8 faculty of health sciences curtin school of allied health curtin university perth western australia australia received 15 july 2021 accepted 3 january 2022 abbreviations additional file 1 table additional file 2 figure s1 ranking of macrolevel elements to facilitate first nations australians selfdetermination presents the rankings by proportion for all responses in q1 for rounds 2 and 3 additional file 3 figure s2 ranking of values that should facilitate first nations australians selfdetermination presents the rankings by proportion for all responses in q2 for rounds 2 and 3 additional file 4 figure s3 ranking of the policy processes needed to ensure selfdetermination is evident presents the rankings by proportion for all responses in q3 for rounds 2 and 3 additional file 5 figure s4 decisionmaking processes needed policy development for selfdetermination presents the rankings by proportion for all responses in q4 for rounds 2 and 3 additional file 6 figure s5 factors necessary for selfdetermination in the implementation presents the rankings by proportion for all responses in q6 for rounds 2 and 3 authors information this review is part of a wider phd study exploring how selfdetermination by first nations australians can be recognized and included in the development of alcohol policy two of the authors including aes are first nations australians providing a first nations australian perspective and world view to this study competing interests the authors declare that they have no competing interests

background recognition of the role of structural cultural political and social determinants of health is increasing a key principle of each of these is selfdetermination and according to the united nations 2007 this is a right of indigenous peoples for first nations australians opportunities to exercise this right appear to be limited this paper explores first nations australian communities responses to reducing alcoholrelated harms and improving the health and wellbeing of their communities with a focus on understanding perceptions and experiences of their selfdetermination it is noted that while including first nations australians in policies is not in and of itself selfdetermination recognition of this right in the processes of developing health and alcohol policies is a critical element this study aims to identify expert opinion on what is needed for first nations australians selfdetermination in the development of healthand alcoholrelated policy methods this study used the delphi technique to translate an expert panels opinions into group consensus perspectives were sought from first nations australians n 9 and nonindigenous peoples n 11 with experience in developing evaluating andor advocating for alcohol interventions led by first nations australians using a webbased survey this study employed three survey rounds to identify and then gain consensus regarding the elements required for first nations australians selfdetermination in policy development results twenty panellists n 9 first nations australian participated in at least one of the three surveys following the qualitative round 1 survey six main themes 60 subthemes and six examples of policy were identified for ranking in round 2 in round 2 consensus was reached with 67 of elements n 4060 elements that did not reach consensus were repeated in round 3 with additional elements n 5 overall consensus was reached on two thirds of elements 66 n 4365 conclusions selfdetermination is complex with different meaning in each context despite some evidence of selfdetermination systemic change in many areas is needed including in government this study has identified a starting point with the identification of elements and structural changes necessary to facilitate first nations australian communityled policy development approaches which are vital to ensuring selfdetermination

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background intimate partner violence has been defined as any behaviour by an intimate partner which causes physical sexual or psychological harm and ipv results in lasting health damage particularly for women and children 1 pregnant women and those with infants are especially vulnerable to ipv 23 during pregnancy ipv has been estimated at between four to eight percent it can commence continue or escalate in pregnancy and continue into the postpartum period 4 with serious physical and emotional consequences 56 this study is located in melbourne australia where ipv among women in the childbearing years is estimated to be the major contributor to the burden of illness amongst women of childbearing age it is also a significant cause of adverse pregnancy outcomes 7 8 9 ipv has a significant impact on womens parenting abilities ultimately compromising their childrens development 9 current research indicates that many children witnessing ipv can experience behavioural emotional developmental and psychobiological problems and difficulties with social competence in the longer term 10 the damage can be incremental but is also cumulative and while some children demonstrate resiliency it is not yet clear why therapeutic services for mothers and their children who have experienced violence are now developing and offer valuable sources of referral if the problem is detected early and referrals made the potential for health services to support women and children experiencing ipv in the early infant years has been recognised with increasing government policies around screening for ipv in the perinatal periods 11 however the evidence of benefit for women and children of screening for ipv is scarce 12 13 14 nevertheless in spite of this lack of evidence screening all women is a common policy initiative and primary health care professionals are increasingly mandated to screen for ipv especially in the childbearing years health care professionals are commonly reluctant to ask about ipv and women may also be reluctant to disclose common barriers for healthcare professionals inquiry have been found to be lack of professional training support resources and workload 15 while there is evidence that training can increase clinician confidence rates of identification and referral in a given study period a major problem is the lack of evidence of the sustainability of healthcare provider behaviour change and evidence for subsequent effective interventions 14 this paper reports the protocol for an ipv screening randomised trial located in maternal and child health nurse clinics in melbourne australia with an evaluation of the elements contributing to sustained screening practice screening for intimate partner violence ipv screening in health care systems can be defined as routine and systematic inquiry of all presenting women about their experience of intimate partner violence using a consistent set of questions 16 it remains a controversial subject as reviewers of the same evidence have come to different conclusions about its effectiveness and as to whether it should be recommended 14 16 17 18 scholars have identified many barriers to universal ipv screening including health care provider attitudes heavy workloads and lack of recurrent training of adequate referral services and other resourcing support and the presence of partners during consultations 14 19 20 21 22 nevertheless governments are increasingly turning to universal screening as a policy option with varying levels of readiness to address the identified barriers to sustaining screening practices there have been varying rates of screening coverage reported depending on whether screening data are collected routinely or snapshots are taken when service providers know their governments are scrutinizing performance at a particular time 16 while routine screening is commonly assumed to be a desirable goal a recent trial of an alternative approach system supported case finding or inquiry when ipv symptoms are present by primary care providers was successful in raising identification and referral numbers although benefits for women are unknown 23 the victorian maternal and child health service and the context for ipcv screening victorian maternal and child health nurses are trained nurse midwives who visit over 95 of all victorian mothers with newborns at home and continue to offer support at their local centres until the children are six years old 24 this free universal comprehensive primary healthcare service aims to provide health promotion illness prevention early detection of developmental problems and intervention to enhance the health and wellbeing of young children and their families australia has three tiers of government federal or national state and local government or council mchn nursing is located and managed in the complex local government environment while implementing policies formulated at state government level they are often funded at local government level in late 2009 just as this proposed trial of ipv screening versus usual care was funded a new comprehensive approach to screening children and their mothers for other common problems and developmental delays key ages and stages was introduced into victorian maternal and child health nursing practice 25 under the new key ages and stages protocol mchns are now required to screen all mothers for family violence the governments preferred term which includes child abuse when their babies are four weeks old mchns were provided with three hours training to use a common risk assessment framework offering a common definition of ipv for health care providers police family violence services and courts symptoms to look for and referral processes included in kas strategies were computer prompts for the now mandated four week ipv screening any screening at a later consultation and the requirement to report regular data about ipv screening safety plans and referrals and other child health screening and referral rates to government nurses are required to ask the following questions about family violence mosaic prior to this government initiative in our previous ipv trial of nonprofessional mothertomother support for pregnant or recent abused mothers known as mosaic 26 mch nurses struggled to identify and refer clients experiencing violence despite comprehensive sixhour training by a domestic violence training agency and additional resources an impact evaluation conducted at the end of the study showed that 66 of nurses said that they were comfortable or very comfortable asking about partner violence while 18 remained uncomfortable thirtyfive percent cited partners or family members being present as the major obstacle to asking about ipv followed by fear of embarrassing women and the need to focus on the child as their priority when asked what made it difficult 42 of nurses said womens reluctance to take further steps referral agencies waiting lists and the difficulty of finding support for women with special needs when asked what should be put in place to assist other nurses to develop their skills and increase their confidence in this area nurses suggested regular training mchn specific clinical guidelines for ipv and an mchn clinical pathway following on from mchn feedback in mosaic this study originally aimed to compare implementation of ipv screening with usual care however with the introduction of mandatory ipv screening of all recent mothers when babies are four weeks old the trial design was modified to evaluate an enhanced model of ipv screening addressing some of the identified challenges for nurses and addressing the issue of sustainability compared with basic mandatory ipv screening trial registration this trial was registered with the australian and new zealand clinical trials registry 1 ethics recruitment of clusters mch nurse teams in north west melbourne team leaders of eight mch teams located in eight local government areas were invited to participate in a previous study mosaic 26 and all agreed each team leader and their manager signed a supplementary letter to the original memorandum of understanding to participate in this subsequent study randomization the randomization of nurse teams at that time occurred at a public randomization meeting names of the mchn teams stratified by numbers of births per local government area and paired in size were concealed in opaque envelopes and the random selection made by an invited guest from outside the project or research team mch team leaders were present to ensure the fairness of the process and to check the contents of the envelopes prior to their being sealed for move all eight teams agreed to the reverse of the previous randomisation allocation so that teams allocated to comparison status in mosaic formed the intervention arm for move and those previously allocated intervention status formed the comparison arm blinding given the nature of the intervention it has not been possible to blind mchn teams or nurses to their status the project coordinator is not blind to mchn team participant status either as she is required to liaise with intervention team mchn consultants women attending the mchn service are blind to their status as randomization is by cluster and consent to participate in the trial was given at mch team level blinding all outcome and process evaluation data are selfcompleted by women and nurses and are anonymous mchn staff complete process and impact survey instruments on line using an anonymised format and data are stored in a secure database mchn complete anonymised routine computerized screen data that are summarized annually and forwarded to the department of education and early childhood development names and addresses of women attending mch clinics are not accessible to research staff because of privacy regulations surveys are sent to women in anonymised questionnaire booklets mailed to their home by a local government agency with an accompanying letter from their mchn team leader outcomes were prespecified at the time of our trial registration analyses are to be carried out by the study statistician blinded for trial arm following data entry of womens survey responses by an independent data company move processes survey sample size calculation we calculated that around 810 of women attending each of the eight mch services will have been abused in the previous 12 months 4 following twelve months implementation we will send a mailed questionnaire to all women who have given birth in the previous 8 months in both the comparison and intervention municipalities this sample size enables us to detect a predicted increase of 15 average disclosure found previously in a screening intervention of screening vs usual care 27 we have taken into account both the numbers of births in participating local government areas the likely response fraction and also adjusted for clustering we adjusted for an intracluster correlation of 002 from a previous ipv primary care study 28 outcome measures routine data data reported routinely to the victorian government is entered at the time of consultation by the mch nurse in relation to ipv screening these data include whether the nurse reports asking about any of three family violence questions to which the answer is yesno and at what time point home visit four weeks eight weeks four eight twelve or eighteen months whether the nurse reports making a safety plan whether the nurse reports making a referral we will compare rates of inquiry safety plans and referrals between intervention and comparison arms at four weeks four months and twelve months survey measures the survey booklet womens experiences of health care and support with a new baby has seven sections about your baby about your own health following your baby your health care support other care and support you receive relationships and family you and your partner about you it is designed to maximize womens safety as it is mailed to her home section f includes questions about intimate partner violence measured using hegartys composite abuse scale 29 together with questions about being asked disclosure rates of referral and satisfaction measures for herself her children and in relation to strategies for her partner the questionnaire also includes depression and anxiety measures using the dass21 3031 womens experiences of motherhood measured with the experience of motherhood scale 32 and a range of other assessments of womens experiences checklists these data will only be available in the intervention arm as they are a screening intervention tool nurses use these screening selfcompletion forms with women and retain these for collection by move research staff they also record the screening consultation time and these will be analysed especially for the three month screening point when routine data are not recorded methods theoretical framework an overarching goal of this study is the development of a sustainable model of mchn good practice in identification support and referral of women experiencing ipv there has been considerable debate about the limitations of programs aimed at enhancing health care professional behavior change 33 further it is now recognized that when interventions themselves are complex and operate in a complex environment that attention to theory process and in particular context are required if they are to be successfully integrated into routine practice 34 this requires greater attention to the development testing and refinement of an intervention before effectiveness testing may et als normalization process theory 35 36 37 proposes four domains of work which require particular attention in the design development implementation and evaluation cycle of health system and health professional behavior change we outline in brief how in relation to the work of mchn we interpreted the core npt concepts in relation to mch nurse work and incorporated this into all aspects of the design development implementation and process and impact evaluation of this trial in terms of the core concepts we interpreted them as related to mch nursing work as follows this phase involved three strategies 1 we conducted participatory action research with four volunteer mchn consultants who explored the barriers and sought answers to these problems within their teams par has been defined as collective self reflective inquiry that researchers and participants undertake so they can understand and improve upon the practices in which they participate and the situations in which they find themselves 38 over a sixmonth period at regular monthly meetings with move staff questions derived from earlier feedback in mosaic 26 discussion about barriers and enablers of ipv screening practices and informed by the npt framework 36 were agreed and nurse consultants took them away to their teams for discussion and feedback the two groups met over a six month period to discuss team feedback and reach agreement on the major aspects of a good practice model to be outlined in clinical pathways and guidelines all meetings were recorded on tape and notes derived from them informed further discussion we also drew on a gp systems intervention then being piloted in the uk for strategies to strengthen links between clinicians and family violence services a systematic review of interventions with controlled or comparison designs guidelines or protocols targeted at improving the response of health care practitioners working with women experiencing ipv their children and partners using abusive behaviors was conducted using medline cochrane and campbell collaboration databases and cinahl further details of the search terms and inclusionexclusion criteria are available from the authors results were synthesized and presented to the nurse consultant and research group and the advisory group of key stakeholders 3 using a method we have previously used in an international collaboration to develop gp guidelines 39 we facilitated multidisciplinary group discussions between the nurse consultants and study reference group to independently score and then reach agreement about the content and format of the guidelines clinical pathway and maternal health checklista womans selfcompletion screening tool a penultimate draft of these materials was presented and finalized at a reference group meeting and further detail of the models key elements are presented below screening time the move intervention model mch nurses expressed concern about an early screening time for the following reasons women were still recovering from the birth and focused their attention on the babys not their own needs nurses had had insufficient time to establish a trusting relationship with the woman which would make it easier to ask a sensitive question and enable disclosure 30 of victorian women have had caesarean section and advised not to drive for six weeks so are frequently accompanied by someone making it sometimes challenging to ensure screening safely nurses therefore suggested that the optimum screening time would be at a three or four month visit when women could be advised ahead of time that the visit would be focused on their needs and that they would be completing a womens health checklist they also suggested that they could ask women not to bring other children if possible and told accompanying partners that the questions would include discussion of menstruation and breast problems and that partners may not want to be present two teams created an additional womanfocused three month visit and the other two teams added fifteen minutes to the four month kasfunded visit to be focused on maternal needs maternal health checklist evidence from the systematic review suggested that women preferred selfcompletion screening methods rather than facetoface screening inquiry the maternal health checklist was developed as a tearoff pad consisting of an a5 set of questions for women to selfcomplete at the agreed consultation which focused on maternal health rather than the development of the baby who is the mch nurses primary client when women arrived at this visit they were given the checklist and asked to complete it in a quiet corner and let the nurse know when finished the checklist consists of a set of questions about maternal health beginning with questions about physical health such as headache nipple or bowel problems then moving to those about depression contraception or drug misuse to the same family violence questions being asked as part of the key ages and stages mandatory screening at four weeks after discussion move added two further questions to this list just before the kas questions we added do you have any problems in your relationships or intimacy with your partner and has anyone in your household ever humiliated you or tried to control what you can or cannot do the first question was seen as useful for women who may want to discuss nonspecific problems in the relationship prior to disclosure and the latter because it is central to intimate partner abusive behavior if a woman ticked any of the relationship or any family violence questions nurses were asked to initiate a discussion about these in ways that felt appropriate and comfortable the completed checklist form is retained as part of the study data collection clinical guidelines and pathway the eightpage guidelines were designed so that the clinical pathway was on the front page and summarized recommended actions and also feature principles of good practice along the bottom these principles are further inside are four sections entitled seek inquire and connect assess and support quality assurance and routine practice this section includes routine team monitoring support for nurses experiencing family violence and mindful practice each section outlines the aims guidelines and implementation issues and details practice including which type of nursethe universal nurse the nurse mentor or coordinatorteam leaderhas responsibility for ensuring implementation nurse mentors nurse mentors volunteer or were chosen by team leaders as those nurses with a special interest in andor skills in family violence practice they provide support to individual nurses in the team struggling with difficult cases or wanting to practice their ipv inquiry skills they act as a practice champion in the team the role of these nurses includes liaising with the family violence liaison officers in communitybased family violence services accompanying mchns who are undertaking a home visit for additional safety where there is or is likely to be ipv facilitating and maintaining discussions within the team about ipv issues acting as a secondary referral debriefing and support person for nurses managing difficult cases of ipv family violence mchn liaison workers move adopted the model outlined in the iris study 20 of a family violence agency staff member who has a special responsibility for liaison with primary care services in this case with the mch nurse teams to strengthen links and referral options these staff are funded employed and managed by the family violence services with agreed responsibility during the trial for attending mchn team meetings to familiarize the team with the fv service and other relevant communitybased services eg community police facilitating referrals and secondary referrals to family violence services providing feedback about referrals debriefing if necessary participating in evaluation interviews the geographical location of the two family violence services resulted in one family violence liaison worker liaising with one team and the other liaising with three teams implementation following all stakeholders agreement with the new model nursing consultants and move staff briefed the intervention teams and provided them all with newly developed resources including a guide to ipv documentation teams undertook to implement the move model over a twelve month period during the intervention period move research staff remained at a distance to enhance sustainability and reliance on research staff was kept to a minimum data collection process evaluation online survey questions for nurses structured using tenets of the normalization process theory 36 were developed in consultation with nurse consultants face validity was checked with assessment by stakeholders in the reference group and they were then piloted with an mch nurse team outside the trial to ensure acceptability relevance and timeliness the online survey was developed for use six months into the implementation year with all participating nurses in both arms to elicit mchn current ipv screening knowledge attitudes and work practices at the same time telephone or facetoface interviews were planned with mch nurse mentors team leaders family violence liaison officers and supervising staff from family violence agencies to elicit factors related to key concepts of the npt framework interviews were conducted by external staff impact evaluation online survey data three months after the end of the intervention a second anonymous online survey of mch nurses in both arms of the study was developed to assess their levels of confidence about and attitudes to ipv screening perceived rates of inquiry about womens and childrens safety referral to family violence agencies for all family members team functioning and support for ipv screening and perceptions of their own safety the surveys and interviews will be repeated two years after the end of the intervention to assess sustainability of the screening processes interviews conducted by external staff with key stakeholders will also be conducted at the end of the intervention and two years later outcome evaluation primary and secondary outcomes routine data with local government permission we will retrieve routine data about family violence described above for the intervention period for all nurses in both arms of the study we will seek to retrieve it again in 2013 two years post intervention womens survey questionnaire we have developed a questionnaire survey to be sent to 10000 women who have given birth over an eight month period this sample gives us power to detect differences in the primary outcome included are all the primary and secondary outcome measures and a valid and reliable measure of intimate partner violence 29 the data management company employed to manage the survey data has been subcontracted to the local government councils who have given the company staff access to women clients addresses they will mail the surveys and two rounds of reminder cards surveys will be returned to the company for electronic data entry and doublecoding checklists move staff will retrieve all checklists retained by intervention nurses at intervention midpoint and after the implementation period has finished data will be checked for completion of screen and screening period data analysis and reporting womens survey the mch consumer survey data will be cleaned doublecoded and entered into a secure database by an external company blinded to the study arms it will then be forwarded to a statistician blinded to study arm womens characteristics for sociodemographic and birth characteristics will be compared by trial arm to ensure that randomization was effective the representativeness of the women responding to the survey will be assessed by comparison with routine perinatal data for all women giving birth in the region for the comparison year all data will be analyzed by intentiontotreat and variance estimates in models will be adjusted for the effect of the clustered selection of participants we will analyze data using contingency table analyses for bivariate and binary logistic regression with robust standard errors for multivariate models for primary outcomes we will analyze data stratified by and adjusted for womens abuse status and for potentially significant confounding variables including womens socioeconomic status for move primary outcomes we will report any difference in proportions by trial arm of screening for ipv will be reported separately and as a screening inquiry composite variable any difference in proportions by trial arm of women reporting ipv who have discussed ipv with their mch nurse any difference in proportions by trial arm of nurses who have reported that they have made safety plans with women clients any difference in proportions by trial arm of women reporting ipv who have been offered a referral or nurses who report they have made referrals for ipv the following measures will be reported for the overall population and also by trial arm any difference in proportions by trial arm of abused and nonabused women reporting satisfaction with their mch nursing care intimate partner violence measured by the composite abuse scale reported for women with scores ≥ 3 and those with scores ≥ 7 proportions ever having been afraid and currently afraid of their partner proportions reporting partner abuse during pregnancy for the recent pregnancy and any in a past pregnancy proportions abused in pregnancy by family members and by other known persons proportions physically sexually emotionally abused or neglected as children proportions reporting harm from ipv screening or participating in an ipv screening study process and impact evaluation online survey data will be downloaded by move staff from the online survey database and entered into an excel spreadsheet responses will be grouped by mchn nurse team and separated into trial arms responses will be counted and proportions of responses for each questions calculated these data will be compared across trial arm and analyzed using bivariate chisquare tests of independence or other nonparametric analytical approaches where appropriate qualitative data will be transcribed verbatim coded thematically exploring npt constructs and for any other significant patterns and any outliers dissemination and translation we propose to present the findings from this study to victorian and australian policymakers at relevant national conferences in person to the victorian government department responsible for mch nursing at international ipv and nursing conferences in peerreviewed and professional journals two year followup we propose to seek permission to obtain routine data for screening inquiry safety plans and referrals for ipv two years after the move implementation completion we will also aim to conduct a survey with all nurses in the two arms of the move trial to investigate the sustainability of the screening intervention using npt constructs analyses of these data will be conducted as outlined above discussion move will be the first randomised trial to determine ipv screening effectiveness in a community based nurse setting and the first to examine sustainability of an ipv screening intervention screening for ipv remains a controversial area but governments especially in high and middle income countries continue to implement screening policy in health care settings without addressing the key barriers reported by primary care professionals especially workloads ongoing training and lack of effective multiagency collaboration without addressing such barriers there is doubt about the sustainability or effectiveness of screening 27 normalisation process theory 36 has been developed to support sustainability of implementation and evaluation of complex interventions and complex settings and is appropriate to the effectiveness and sustainability questions addressed by the move trial this study is being conducted in victoria australia where legal sanctions and strong family violence policies exist at national and state level as a high income country crisis and outreach responses for women are funded and supported improved policing responses and interventionprotection orders available from magistrates courts tailored to family violence victims are also available there are also behaviour change groups for male perpetrators and services for children who have experienced family violence in this context when primary care providers identify women experiencing family violence services exist to support women and sanctions are available to prevent further harm as a result of previous training conducted in the mosaic study and the further training offered in the new victorian key ages and stages initiative move nurse teams in both arms of this study have been well trained to screen and refer women experiencing violence of all victorian mch nurses nurses in this study are well prepared and the intervention arm nurses even better prepared following their active involvement in developing a good practice model move results will further inform the debate about the effectiveness of ipv screening and describe ipv prevalence in a community based postpartum and early infant population competing interests the author declare that they have no competing interests

background intimate partner violence ipv can result in significant harm to women and families and is especially prevalent when women are pregnant or recent mothers maternal and child health nurses mchn in victoria australia are communitybased nursemidwives who see over 95 of all mothers with newborns mchn are in an ideal position to identify and support women experiencing ipv or refer them to specialist family violence services evidence for ipv screening in primary health care is inconclusive to date the victorian government recently required nurses to screen all mothers when babies are four weeks old offering an opportunity to examine the effectiveness of mchn ipv screening practices this protocol describes the development and design of move a study to examine ipv screening effectiveness and the sustainability of screening practice methodsdesign move is a cluster randomised trial of a good practice model of mchn ipv screening involving eight maternal and child health nurse teams in melbourne victoria normalisation process theory npt was incorporated into the design implementation and evaluation of the move trial to enhance and evaluate sustainability using npt the development stage combined participatory action research with intervention nurse teams and a systematic review of nurse ipv studies to develop an intervention model incorporating consensus guidelines clinical pathway and strategies for individual nurses their teams and family violence services following twelve months implementation primary outcomes assessed include ipv inquiry ipv disclosure by women and referral using data from mchn routine data collection and a survey to all women giving birth in the previous eight months ipv will be measured using the composite abuse scale process and impact evaluation data online surveys and key stakeholders interviews will highlight npt concepts to enhance sustainability of ipv identification and referral data will be collected again in two years discussion move will be the first randomised trial to determine ipv screening effectiveness in a community based nurse setting and the first to examine sustainability of an ipv screening intervention it will further inform the debate about the effectiveness of ipv screening and describe ipv prevalence in a community based postpartum and early infant population

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introduction despite significant progress in womens labor force participation large gender gaps in labor market outcomes remain across many countries in rich nations most of the remaining gaps can be traced to parenthood which has been shown to lead to significant and lasting setbacks in womens careers relative to men recent work has highlighted the importance of gender norms in hindering progress towards gender convergence traditional norms attribute to women the role of main caregivers within the family and limit their labor market choices after having children previous research has shown that gender norms are passed on from parents to children such strong intergenerational transmission may perpetuate gender inequality at home and render public policies largely ineffective in eradicating the existing gender differentials in the labor market we provide novel evidence that public policy can promote gender convergence in the long term by shaping the gender norms of the next generation to that end we focus on paternity leave an increasingly popular family policy designed to incentivize less traditional specialization patterns within households paternity leave takes place at the onset of a childs life and may trigger persistent changes in the division of paid and unpaid work among parents in particular paternity leave has been shown to increase fathers contribution to childcare and household work persistently with evidence from the us canada germany norway and spain this shift towards a more genderneutral home environment may affect the formation of gender norms at an early age and promote gender equality in the next generation 1 to provide causal evidence we take advantage of the introduction of paternity leave in spain in 2007 the reform entitled new fathers to 13 days of fully compensated paternity leave while this policy change seems small previous research shows that the reform was well received and triggered important changes within couples promoting gender equality in the home and in the labor market specifically the introduction of paternity leave led mothers to return to work earlier after childbirth and induced fathers to become more involved in childcare an effect which was still detectable several years after childbirth we base our identification on the sharp cutoff date determining fathers eligibility for paternity leave the new law was passed shortly before implementation and fathers were entitled to the benefit only if their child was born on or after march 24 2007 thus the reform represents an ideal natural experiment allowing us to isolate the effects of paternity leave on the gender norms and behavior of children whose parents were eligible for the permit to take advantage of this quasiexperimental setting we conducted a large labinthefield experiment with children born in 2006 and 2007 ie the reform year and the previous one we collaborated with secondary schools in the region of catalonia and surveyed more than 2000 children between may 2019 and january 2020 when the target children were 11 to 13 years old 1 fernández et al show that the wives of men who were brought up in families where the mother worked are themselves significantly more likely to work bertrand also documents that children growing up in nontraditional families display more genderegalitarian attitudes we rely on stateoftheart survey and experimental methods to elicit comprehensive data on childrens own attitudes and opinions regarding gender roles in the family and the workplace as well as on their perceptions of the gender norms prevailing among their peers both types of measures are relevant since behaviors may be driven by childrens beliefs about other peoples opinions on top of their own attitudes and views moreover we asked children about their daytoday contributions to household chores and about their expectations regarding their own future work and family life combining our unique labinthefield experiment with the natural experiment we follow a local differenceindifferences strategy to estimate the causal effect of paternity leave on childrens gender norms behaviors and expectations a compelling feature of the paternity leave reform is that it became effective on march 24 which lies in the middle of the school year as a result children born shortly before and after the cutoff date attend the same school grade while only children born after the cutoff are directly affected by the paternity leave expansion our baseline specification relies on comparing children born in a 12week window before and after the paternity leave introduction ie children born between january 1 and june 12 of 2007 to isolate any relative age or season of birth effects we use children born in the same time window in the prereform year as a control group we also control for a set of individual background characteristics as well as school fixed effects our results show that the introduction of paternity leave led to children displaying significantly more genderegalitarian attitudes it also affected childrens perception of the prevailing social norm there is an 18 percentagepoint increase in the share of children stating that it is socially appropriate for a woman with young children to work and a 16 percentagepoint increase in the share stating that it is socially appropriate for a father to work less than full time thus the introduction of paternity leave affected childrens norms regarding both mothers and fathers to a similar extent the results on childrens gender role attitudes and norms are remarkably stable in size and across a battery of robustness checks including alternative sample specifications and estimation approaches turning to revealed behaviors we find that the introduction of paternity leave promoted less specialized gender patterns in childrens daytoday contributions to home production specifically children born after the reform are 14 percentage points more likely to engage in counterstereotypical household tasks girls get more involved in male chores such as small repairs and grocery shopping while boys increase their contribution to female household chores such as cleaning finally children born after the reform are 16 percentage points more likely to report counterstereotypical expectations regarding their own future work and family life boys are less likely to expect working fulltime when they have children while girls do more so all in all our findings provide compelling evidence that the introduction of paternity leave in spain induced the next generation to step away from traditional gender norms and stereotypical behaviors it is still too early to learn about the effects of this policy on childrens labor supply choices nevertheless taking childrens expectations regarding their own future work and family life at face value our results suggest that paternity leave has the power to narrow the gender gap in labor market outcomes in the next generation our study provides novel evidence on the extent to which public policy can shape gender norms across generations there is only limited previous evidence showing that public policy can causally influence gender norms and much less intergenerationally focusing on the earned income tax credit implemented in the u s in 1975 bastian documents how the subsequent rise of working mothers changed the us economy and the role of women in society in particular the approval of working women in the same generation 2 our study focuses instead on a policy targeting parents and its potential to change gender norms and labor market decisions in the next generation as such we also contribute to a scarce but growing literature on spillover effects of public policies more broadly our paper contributes to the growing literature on the determinants of gender norms we provide causal evidence on the role of parents in shaping childrens gender norms or in other words on vertical socialization mechanisms as such our research relates to recent work on horizontal socialization mechanisms such as school and peers dhar et al evaluate the impact of a schoolbased randomized intervention in india that engaged adolescents in classroom discussions about gender equality the intervention not only fostered more progressive gender attitudes but also induced more genderegalitarian behaviors the effect sizes of their intervention a twoandahalfyearlong pedagogical program in school are comparable to ours those of a policy inducing a permanent shift in childrens home environment and thus the everyday impressions children gather over their entire childhood studying the gender composition in vietnamese schools garciabrazales finds that exposure to more female peers erodes traditionalism both for boys and girls which translates into actual behavior 3 2 there is also crosscountry evidence on the impact of childcare provision and of samesex relationship recognition policies on attitudes in europe 3 relatedly olivetti et al show that labor force participation of high school peers mothers affects adult womens labor force participation above and beyond the effect of their own mothers for japan hara and rodríguezplanas show that the elimination of gendersegregated topics classes in secondary schools led to less gendered behaviors at home and in the labor market dahl et al study the effect of young mens exposure to women in a traditionally maledominated environment their context is the military in norway where they randomly assigned female recruits to some squads but not to others during boot camp while living and working with female colleagues for eight weeks induced more egalitarian gender attitudes the effects did not persist in sum while the number of studies on the role of peers in shaping gender norms is growing we provide novel evidence on the role of parents 4 the remainder of the paper is organized as follows the following section describes the paternity leave reform and summarizes previous findings regarding its effects on the parent generation section 3 provides detailed information on our data section 4 explains the empirical approach section 5 shows the results and section 6 concludes the paternity leave reform institutional background the focus of this study lies on the introduction of paid paternity leave in spain in 2007 prior to the reform the spanish labor market displayed a significant gender gap in employment patterns 5 in 2006 the employment rate among 3045yearold men reached almost 90 while only two thirds of all women in this age range were working at that time spain granted 6 weeks of compulsory maternity leave plus 2 days of paid job absence for fathers 67 in addition families were granted 10 weeks of parental leave also at full pay which could be taken by mothers or fathers or shared between them yet as shown in figure 1 very few fathers took parental leave in contrast roughly two thirds of all mothers in spain and three quarters of all mothers in catalonia were taking maternity leave and subsequently parental leave 8 employment rates for women after childbirth were low only 55 of all women with children aged 02 were working at the end of 2006 the national parliament approved a bill introducing a paid paternity leave permit the law was published on march 23 2007 and enacted immediately thereafter the new 13day paternity leave period was fully compensated and it could be taken by fathers either at the same time or immediately after the mothers leave period new fathers were eligible starting from births taking place on march 24 2007 if they were affiliated to social security and had worked for at least 180 days over the previous 7 years as shown in figure 1 effective takeup was high with 47 of new fathers in spain and 53 of new fathers in catalonia using it in 2007 9 the paternity leave permit was extended several times thereafter reaching 16 weeks in january 2021 6 parental leave was initially regulated by the law 81980 march 10 eligibility was tied to a formal work contract or to being officially registered as unemployed 7 the exception were public sector workers who enjoyed 10 days of paternity leave since 2005 and public employees of the catalan government who were entitled to 4 weeks of paternity leave since 2006 8 this seemingly low share can be explained by the low share of women under a formal contract in spain in 2006 9 the numbers reported for 2007 refer to new fathers whose child is born on or after march 24 paternity leave inducing a persistent shift in gender equality at home paternity leave is an increasingly popular policy across many countries with the aim to trigger persistent changes within families that go beyond the mere takeup of paternity leave a few studies have evaluated its direct effects along several dimensions the existing literature suggests that paternity leave does not have a large impact on gender convergence in the short term most studies find no effects on fathers subsequent labor market outcomes farré and gonzález similarly report no effect on fathers employment and earnings of the introduction of paternity leave in spain in 2007 the evidence on mothers labor supply is more mixed eckberg et al dahl et al and rege and solli find zero effects of paternity leave policies in sweden and norway and thus in countries with an a priori higher female labor force participation patnaik however finds some positive effects for canada and farré and gonzález and gonzález and zoaby find small positive effects for spain demonstrating that the introduction of paternity leave in 2007 led to women going back to work earlier after childbirth turning to gender equality at home there is substantial alignment in previous studies finding that paternity leave triggered important and lasting changes specifically there is evidence that paternity leave increases fathers involvement in childcare and household chores persistently such effects are found by kotsadam and finseraas and rege and solli for norway patnaik for canada and tamm for germany farré and gonzález and gonzález and zoaby provide similar evidence for spain using timeuse data for 2009 and 2010 and employing a regression discontinuity framework they show that fathers exposed to the introduction of paternity leave spent on average about an hour more per day in childcare and housework and this even several years after the birth of the child strikingly the reform in spain also led to a delay in subsequent births and ultimately fewer births especially among older couples with mothers being 30 years and older moreover the simultaneous reduction in mens desired fertility and the subsequent reversal of the prereform pattern of men desiring more children than women point to an increase in mens awareness of the costs of child rearing 10 finally a recent study by tavits et al shows that the extension of paternity leave in estonia in 2020 exerted a sizeable increase in genderegalitarian attitudes among both new mothers and fathers in sum the literature suggests that paternity leave has the power to induce a shift towards more gender equality at home and in particular towards children experiencing less genderstereotypical parental behaviors this is thus the main mechanism that we propose as a channel driving our estimated effects on childrens gender role attitudes opinions and norms data setting and study implementation our central idea is to use comprehensive data on gender norms among children in a quasiexperimental framework our identification strategy relies on the introduction of paternity leave in spain a necessary condition for the implementation of our empirical approach is a large sample of children born in a narrow window around the reforms enactment date to reach this group of children and to ensure a large enough number of observations for children from all family backgrounds we opted to collect our own data and to run a survey in schools we collaborated with 16 selected secondary schools in the region of catalonia in 201920 11 we targeted all children attending 5 th to 7 th grade and thus children at the onset of adolescence a critical time in the development of identity and social norms formation our sampling design allowed us to reach all children within designated social networks data collection occurred in two phases the pilot phase took place between may 20 and may 24 2019 during this phase we collected data in 3 schools all together 15 classes with 401 students the second phase happened between january 13 and february 7 2020 we visited 13 additional schools 80 classes with 1926 participants altogether 12 the study was preregistered 13 and approved by the ethics and data protection office at universitat pompeu fabra a week before data collection schools informed parents about the study and its general purpose but not the specific research question by email and gave them the option to withdraw their consent regarding their childrens participation 14 the survey took place during regular instruction time which ensured that we could reach all students at the beginning of the survey we informed students about the general purpose of the study without providing details about our specific research question 15 we also gave them the option to not participate or to drop out at any point during the survey students were paid a showup fee and could earn points in several incentivized parts of the survey which were later exchanged for vouchers valid at a nearby stationary store participants received on average 573€ with a minimum of 3€ and a maximum of 12€ data collection took place in a designated room inside the school where we installed 35 laptops students came to the room together with their classmates in groups of 14 to 32 students to ensure privacy we set up cardboard screens between the students to avoid priming effects the order of the questions was randomized students answered all questions individually and at their own pace they needed on average 27 minutes to complete the questionnaire students who completed the questionnaire early were asked to stay in the room reading in silence out of the 2327 students present in the classroom on the day of the study 9 did not consent to participate 8 dropped out during the survey 9 were not able to answer the questions without help and information for 1 participant was not stored the questionnaire and the outcome variables to yield a comprehensive set of measures for childrens gender norms we employed both classical survey and incentivized experimental methods we further included questions asking students about their daytoday behaviors and their expectations regarding their own future employment and 15 the precise information given to the students is shown in appendix b2 fertility 16 table a1 in appendix a provides an overview of our main outcome variables including summary statistics at baseline for the prereform sample our first measure of interest are childrens attitudes about gender roles for this purpose we employed a standard battery of questions developed by the international social survey programme and widely used in the economics literature on gender norms 17 specifically we asked students to rate on a 5point likert scale whether they agreed or disagreed with a series of 7 statements regarding the role of men and women in the labor market and in the home we use the standardized first component of a principal component analysis as our gender role attitudes index 18 second we elicited childrens individual opinions on whether a woman with a child below school age should work fulltime parttime or not at all 19 we again drew on a widely used question from the issp we also asked children about their opinion on whether a man with a child below school age should work fulltime parttime or not at all doing so allows us to assess and compare childrens answers for both parents and to acknowledge that children may be egocentric and ideally want their parents to work less and spend more time with them all together 20 summarizing the answers to counterstereotypical labor market behavior we create indicators for childrens individual opinions about mothers taking the value 1 if reported that a mother with a child below school age should work parttime or fulltime and individual opinions about fathers taking the value 1 if reported that a father with a child below school age should work parttime or not at all third we introduced an incentivized elicitation method to get at childrens perception of the prevailing social norm on mothers and fathers labor supply we adapted the incentivized coordination game developed by krupka and weber to be appropriate for children we explained the game to the children as follows you will now play a little game with one of your classmates without knowing who she is in this game we will ask you both the same question if you both give the same answer you will both earn 4 points if you do not give the same answer no one will get any points 21 after ensuring that the children 19 in spain children are granted public education from the year during which they turn 3 years old as a result 98 of all 3yearolds are enrolled in school 20 indeed most prereform children want men and women with young children to work parttime there is even a sizable share that prefers parents not to work at all note there is a divide in terms of gender as 25 want women with young children not to work but only 14 want men with young children not to work 21 payments were calculated based on random matching and made at the end of each session understood the coordination aspect of the game using several control questions 22 we asked the children to rate on a 4point likert scale how socially appropriate it is that a woman with a child below school age works fulltime that a woman with a child below school age works parttime that a father with a child below school age works parttime and that a father with a child below school age does not work at all we were very careful in explaining the meaning of socially appropriate as a behavior that most people believe to be correct or good importantly presenting these questions as an incentivized coordination game encourages children to consider not only their own opinions but also the opinions of others and how they align with each other as such these questions reveal their perception of the social norms prevailing among their classmates we aggregate childrens responses regarding the social appropriateness of mothers working fulltime or parttime and fathers working parttime or not at all and create indicators for childrens social norms about mothers and social norms about fathers 23 turning to genderstereotypical behaviors we collected information on childrens participation in household chores we asked them how often they help at home with the following tasks laundry grocery shopping small repairs cleaning the house and cooking we then create the indicator counterstereotypical behavior which equals 1 if a boy engages at least occasionally in primarily female chores and 0 otherwise or if a girl engages at least occasionally in primarily male chores and 0 otherwise 24 finally to get as close as possible to childrens future labor supply choices we collected information on childrens expectations about their own future family and work life we asked them how do you see yourself in 20 years from now answer categories were working fulltime and having children working parttime and having children not working and having children working and not having children and not working and not having children 25 we summarize childrens expectations regarding future work and family life in an indicator measure that we refer to as counterstereotypical expectations the variable equals 1 if a girl expects to work fulltime and have children or if a boy expects to not work fulltime and have children sample we exclude from the sample all children not born in 2006 or 2007 and those not born in spain the reason for the second restriction is that the parents of children born abroad were not subject to the paternity leave reform our final sample contains 1987 children born in spain in 2006 or 2007 24 the share of boys and girls engaging in the different household chores is shown in table a1 panel d we define a chore as a primarily male chore if the share of boys engaging in the respective chore significantly exceeds the share of girls this results in doing small repairs and grocery shopping being a primarily male chore and cleaning being a primarily female chore the other tasks such as doing the laundry or cooking are largely gender neutral note that if a girl engages in either of the two primarily male chores the variable equals 05 for girls 25 interestingly the most popular choice among prereform boys and girls is to have children and work parttime yet there is a substantial gender gap when it comes to having children and working fulltime a substantial share of prereform children both boys and girls see themselves as not having children table a2 shows the summary statistics for the full sample children in our sample are on average 13 years old and are almost equally split by gender by construction all children are born in spain but roughly one tenth has at least one parent born abroad most children live with both parents but a nonnegligible share lives with their father only on some days or not at all among the fathers 67 work fulltime and 24 work parttime 5 do not work among the mothers 50 work fulltime 37 work parttime and 10 do not work half of the mothers went to college and slightly fewer fathers did so yet a nonnegligible share of the children does not know whether their mother or their father went to college empirical strategy our identification strategy is based on the introduction of paternity leave in spain applying to fathers of children born on march 24 2007 or later we employ a differenceindifferences model comparing children born shortly before and after the cutoff date in the reform year drawing upon children born in the same window of birthdates in a control year 26 hence we estimate the following equation 26 the natural experiment under study is obviously suited for a regression discontinuity design given the limited sample size only some of our outcomes are robust to an rdd specification while we lack power when it comes to others similar identification strategies have been used by lalive and zweimüller dustmann and schönberg danzer and lavy and schönberg and ludsteck in the context of parental leave reforms 𝑌 𝑖 𝛽 0 𝛽 1 𝐶𝑜ℎ𝑜𝑟𝑡2007 𝑖 𝛽 2 𝑃𝑜𝑠𝑡𝑀𝑎𝑟𝑐ℎ24 𝑖 𝛽 3 𝐶𝑜ℎ𝑜𝑟𝑡2007 𝑖 𝑃𝑜𝑠𝑡𝑀𝑎𝑟𝑐ℎ24 𝑖 𝑋 𝑖 𝜀 𝑖 where 𝑌 𝑖 stands for the gender norms behaviors or expectations exhibited by child i 𝐶𝑜ℎ𝑜𝑟𝑡2007 𝑖 is a dummy variable indicating whether child i is born in 2007 and 𝑃𝑜𝑠𝑡𝑀𝑎𝑟𝑐ℎ24 𝑖 represents a dummy variable taking the value 1 if child i is born on or after march 24 the interaction term 𝐶𝑜ℎ𝑜𝑟𝑡2007 𝑖 𝑃𝑜𝑠𝑡𝑀𝑎𝑟𝑐ℎ24 𝑖 takes value 1 for any child born after the introduction of paternity leave we can thus interpret the coefficient 𝛽 3 as the intenttotreat effect of paternity leave on childrens gender norms expectations and behaviors 27 we restrict the baseline sample to the 873 children born 82 days around the cutoff date march 24 28 hence we compare children who belong to the same school cohort and are thus subject to the same school cohort specific factors in our preferred specification we control for individual background characteristics and for school fixed effects allowing us to abstract from selection into schools we cluster standard errors at the class level to account for the sampling procedure as in abadie et al 2022 the identifying assumption underlying our identification strategy is a common dateofbirth trend in our outcome variables across the two cohorts in the absence of the paternity leave reform figure 2 displays the dateofbirth trend 28 ideally we would include june 13 yet for data protection issues we could ask children only whether their birthday fell into windows of 812 days and not for their exact birthdate 29 we make use of the information about the range of days when a child was born the dateofbirth fixed effects thus indicate whether a child is born in a window of 812 days within a calendar year and apply to all children born in the respective window independently of the year of birth we also assess whether the preand postreform children are balanced in terms of observable covariates table a2 shows the preand postcutoff date means for a series of individual background characteristics in our baseline sample columns 23 for the children of the treated cohort and columns 45 for the control cohort column 6 reports the differenceindifferences estimates for all individual background characteristics reassuringly none of the estimates is significant at the conventional levels results effects on childrens gender role attitudes opinions and norms this section describes the estimated effects of the reform on our measures of gender role attitudes opinions and norms using the empirical model in equation table 1 displays the point estimates for 𝛽 3 the coefficient on the interaction between the reform indicator and the dummy indicating the treated cohort column 1 shows the coefficient when estimating equation without controls column 2 when adding individual background characteristics and column 3 when further including school fixed effects panel a reports the results for the reform effect on the gender role attitudes index the individual opinions and the perceived social norms regarding the labor supply of mothers starting with the first row in panel a of table 1 and the most parsimonious specification we find a positive reform effect on childrens gender role attitudes index of 021 standard deviations the magnitude of the coefficient increases to 026 standard deviations when controlling for individual background characteristics and after including school fixed effects with an accompanying improvement in precision in what follows we will only refer to the most conservative specification in column turning to childrens individual opinions we find that the introduction of paternity leave exerts a strong effect on childrens individual views about mothers the share of children stating that a mother with a child below school age should work increases by 146 percentage points given the share of prereform children supporting deviations from the stereotypical maternal behavior the estimated reform effect corresponds to an increase by 22 or 031 standard deviations in the support towards working mothers childrens perceptions regarding the social norm about working mothers are also affected by the introduction of paternity leave the share of children perceiving it as socially appropriate or at least fairly appropriate that a mother works increases by 179 percentage points corresponding to an increase by 28 or 037 standard deviations 30 panel b displays the reform effects on childrens opinions and norms about the labor market behavior of men with children below school age we find no significant effect of the introduction of paternity leave on childrens individual opinions regarding fathers labor supply in the eyes of most prereform children fathers should work either parttime or not at all if we consider this extremely high baseline of children endorsing father counterstereotypical labor market behavior it is not surprising that the introduction of paternity leave did not exert any effect at this margin turning to childrens perception of the social norm we find a significant increase in the share perceiving it as socially appropriate that a father works parttime or not at all this share rises by 163 percentage points which corresponds to an increase by 36 or 033 standard deviations thus the policy has shifted norms applying to mothers and fathers to a similar extent overall the results in panel a and b of table 1 provide compelling and robust evidence of substantial spillover effects of paternity leave on to the next generation no matter which measures we look at we find that the policy promoted genderegalitarian attitudes and norms among children of eligible parents 31 parents seem to exert a strong influence on the formation of childrens gender norms that may go beyond that of peers at this early stage of life if children were perfectly informed about their peers gender norms we would not be able to detect any effect on childrens perception of the norms prevailing among their classmates yet instead children seem to internalize what they observe at home and draw conclusions from their own experiences about the experiences of others the effects reported so far are intentiontotreat effects when rescaled by the estimated fraction of fathers who actually took paternity leave our point estimates for the average effect on the treated amounts to around half of a standard deviation or more these are large magnitudes which should be interpreted with caution since our 95 confidence interval includes effect sizes as low as 002 standard deviations 007 standard deviations and 009 standard deviations and 001 standard deviations to put our findings into perspective we compare our results to the ones of two recent studies on horizontal socialization mechanisms the schoolbased randomized intervention in india studied by dhar et al that engaged adolescents for two and a half years in classroom discussions about gender equality increased counterstereotypical gender attitudes of 17yearolds by 018 standard deviations studying the impact of classroom composition on gender role attitudes of 15yearolds in vietnamese schools garciabrazales finds that a 10percentage point increase in the proportion of female classmates decreases traditional views by about 015 standard deviations our study thus lines up with a recent literature showing that gender role attitudes among adolescents are amenable to change and contributes to this literature by shedding novel light on the power of public policies to shape social norms by affecting gender equality at home fathers were entitled to paternity leave for any child born on or after march 24 2007 as such children may have directly benefitted from their father taking paternity leave after their own birth as well as indirectly after the birth of a younger sibling the latter also applies to children born prior to the reform to ensure a clean control group we estimate our baseline specification using a sample excluding all children born prior to the reform with younger siblings results on gender role attitudes and social norms are robust and indicate if anything stronger effects the results on individual opinions however loose in size and precision 32 we probe robustness to two further alternative sample specifications first excluding the data collected during the pilot phase and second including all children born in 2006 and 2007 the resulting estimates are robust but slightly less precise robustness we also investigate the robustness of our estimates to alternative estimation strategies first we include a set of class fixed effects considering potential sorting into classes and spillover effects within classes results are extremely robust and shown in table 2 panel a and b column 6 second we exploit the cutoff date and employ a regression discontinuity design specifically we add the running variable to our differenceindifferences specification which results in a socalled rdddid specification again results are remarkably robust to this specification both in terms of magnitude and precision we then turn to a classical rdd design using the full sample and controlling for the running variable as a first order polynomial 33 we find robust estimates for the reform effect on individual opinions and social norms the estimate for gender role attitudes however loses in magnitude and precision 34 33 we use the rdrobust command in stata and rely on all children born in 2006 and 2007 to determine the optimal bandwidth 34 we have further probed the robustness of our results when using alternative aggregation schemes to generate the gender role attitudes index such as a principal component analysis an unweighted average and a weighted average with weights constructed by normalizing the variables to have the same standard deviation and then recovering the weights from the inverse covariance matrix we have employed these different aggregation schemes to construct the gender role attitudes index relying on the 7 original items used in the issp questionnaire as well as considering further the 2 items used for explorative purposes and the 2 questions used to construct the individual opinions regarding both working mothers and fathers the results are remarkable robust across all specifications we also assess the sensitivity of our estimates to acknowledge possible alternative correlation structures between potential outcomes not only within classes but also within schools moreover we consider the close topicality of our outcome variables and adjust for two multiple hypothesis testing results are robust across all specifications finally we conduct a series of placebo tests first we estimate our baseline specification using a placebo outcome childrens perception of the social norm on cheating in an exam we introduced the question on the social appropriateness of cheating in an exam merely to check whether the children had understood the coordination game the introduction of paternity leave and the subsequent counterstereotypical behavior of parents should have left the perception of the social norm on cheating unaffected indeed as shown in figure 3a the reform effect is indistinguishable from zero this zero result removes any concerns that the strong and robust results on social norms may be driven by postreform children reacting stronger to incentives or knowing how to play such an experimental paradigm second we replicate our baseline specification using alternative placebo cutoff dates when no reform took place specifically we use samples of 82dayswindows around a series of hypothetical placebo cutoff dates in 2007 starting from june 12 until october 12 out of the 64 placebo estimations only one is significant at the 5 significance level and two at the 10 significance level this battery of placebo tests probes the robustness of our findings against a multitude of concerns including any differential earlylife experiences children born over the specific 24months window may have made effects on childrens behaviors and expectations an open question is to which extent the paternity leave reform has the power to induce genderegalitarian behaviors and choices contributing to a closure of the gender gap in the future children in our sample are obviously too young to explore the effects of the reform on their labor market outcomes yet the collected information on childrens daytoday contributions to several household chores can enhance our understanding of whether the paternity leave reform may shift gender specialization at home already at a young age information on childrens expectations regarding their own future employment and family plans allows us to get a first glimpse on the potential effects of paternity leave on the future gender gap in labor market outcomes table 1 panel c reports the reform effect on childrens engagement in counterstereotypical household chores to recall counterstereotypical behavior refers to boys engaging at least occasionally in primarily female chores and girls engaging in primarily male chores according to our most preferred specification shown in column 3 if fathers are eligible for paternity leave children are 142 percentage points more likely to engage at least occasionally in counterstereotypical household chores this reform effect corresponds to an increase by 24 or 035 standard deviations breaking the results down by gender reveals that girls are more likely to contribute to male chores such as going grocery shopping and doing small repairs in our most preferred specification in column 3 the reform effect corresponds to an increase by 125 percentage points or 22 boys contribution to male chores in contrast remains unchanged note however the genderspecific estimates regarding the contribution to male chores are not significantly different from each other boys in turn are more likely to contribute to female chores such as cleaning the reform effect corresponds to 15 percentage points or 23 and significantly differs from the reform effect on girls contribution to female chores turning to childrens family and labor market expectations we find that children born after the reform are 155 percentage points more likely to expect deviating from the traditional malebreadwinner model to recall this implies for girls to expect working fulltime and having children and for boys not working fulltime and having children the reform effect corresponds to an increase by 42 from the prereform mean or 032 standard deviation table 3 panel c reports the results for family and labor market expectations separately for boys and girls the results exhibit a genderspecific pattern boys whose father was eligible for paternity leave are 198 percentage points or 80 less likely to see themselves working fulltime and having children this effect is quite sizeable mostly because of the relatively low share of prereform boys planning to work fulltime and having children in the future 35 girls in contrast are more likely to see themselves working fulltime and having children the estimated reform effect corresponds to an increase in 81 percentage points or 60 again a sizeable effect driven by the relatively low share of prereform girls planning to work fulltime and having children yet the reform effect for girls is not statistically significant at the conventional levels 36 overall the results provide strong and robust evidence that paternity leave is a powerful tool to shift not only the gender role attitudes and norms of the next generation but to induce gender convergence both at home and in the labor market as such this policy promises to sustainably combat the gender gap in the labor market and to close the child penalty in the longrun 35 we do not find any effect on childrens fertility intentions the results are available upon request 36 the entire battery of robustness testsalternative sample specifications and alternative estimation strategies is shown in table 2 panel c and d conclusions despite remarkable improvements gender gaps in employment and earnings are still sizable and persistent in all countries much of the current debate on the mechanisms underlying the remaining differentials deals with the existence of social norms on the role of women in childcare and home production many scholars go as far as proclaiming gender norms to constitute an important barrier to gender equality that render family policies largely ineffective yet gender norms are very persistent and transmitted from one generation to the next we study the extent to which family policy can shape gender norms and induce gender equality in the next generation by promoting counterstereotypical behaviors among parents we exploit the introduction of paternity leave in spain as an exogenous shock that increased fathers participation in childcare and housework persistently we conduct a large targeted labinthefield experiment with 1113years old children to elicit their attitudes towards gender roles their individual opinions and perceived social norms on working mothers and fathers we also ask them about their engagement in daytoday behaviors and expectations regarding their future labor market participation we follow a local differenceindifferences approach that compares children born around the date of the introduction of paternity leave on march 24 2007 using the previous cohort as controls we find that children whose fathers were eligible for paternity leave display significantly more gender egalitarian norms and behaviors at age 1113 children born after the reform also report less stereotypical expectations regarding their own labor market involvement after parenthood our results speak to the presence of longrun effects of public policies operating through slowmoving changes in norms that existing quasiexperimental studies have missed figure 1 takeup of parental leave and paternity leave in catalonia and spain note the blue lines represent the percentage of mothers on paid parental leave the black lines represent the percentage of fathers who used at least some weeks of the shared parental leave permit and the red lines represents the percentage of fathers on paternity leave the darkcolored lines refer to the takeup rates in catalonia while the lightcolored lines to that in spain data are obtained from the administrative registers of the spanish national security system for several years the figure shows the reform effect on the perception of the social norm regarding cheating during an exam using our preferred specification and sample specifically children are asked copying in an exam is appropriate fairly appropriate fairly inappropriate or inappropriate note that we show the reform effect using two alternative ways of aggregating childrens answers on the left we show the result when using the four answer categories and standardizing the variable to have a mean 0 and a standard deviation 1 for prereform children on the right we show the results when creating a dummy being equal to 0 for the category inappropriate and 1 otherwise the latter aggregation scheme corresponds to a median split and thus considers the fact that most children choose the answer category inappropriate note each coefficient stems from a separate regression and corresponds to the ols estimate of the coefficient on the interaction term in equation column shows the results without controls column when controlling for individual background characteristics and column when adding school fixed effects the gender role attitudes index is the first element resulting from a principal component analysis of the seven issp questions on gender roles the index has been standardized to have mean 0 and standard deviation 1 for prereform children individual opinions about mothers is a dummy variable that equals 1 if the child believes that a mother with a child below school age should work fulltime or parttime and 0 otherwise social norms about mothers is a dummy variable that equals 1 if the child answers that it is socially appropriate or fairly socially appropriate that a mother with a child below school age works fulltime or parttime and 0 otherwise individual opinions about fathers is a dummy variable that equals 1 if the child believes that a father with a child below school age should work parttime or not at all and 0 otherwise social norms about fathers is a dummy variable that equals 1 if the child answers that it is socially appropriate that a father with a child below school age works parttime or not at all and 0 otherwise counterstereotypical behavior is the weighted average of whether children participate at least occasionally with a counterstereotypical household chore counterstereotypical expectations is a dummy that is 1 for girls when they expect to work fulltime and have children and 0 otherwise the lower number of observations in some questions is because they were not collected in the pilot sample standard errors are clustered at the sessionclass level and shown in parentheses p 01 p 005 p 0 012007 and 23032007 to show the descriptive statistics at baseline column includes both girls and boys while column is restricted to girls and column to boys column displays the gender gap in the different measures panel a displays the share of prereform children providing a nontraditional answer to the battery of gender role attitudes questions taken from the issp for question and it shows the percentage who strongly agree or agree for questions and it displays the percentage who strongly disagree or disagree the gender role attitudes index is the first element resulting from a principal component analysis of the seven questions the index is normalized to have mean 0 and standard deviation 1 for prereform children panel b displays respondents opinion about the optimal labor supply of parents with young children missing categories are i dont know and i dont want to answer individual opinion about mothers is an indicator that takes value 1 if the child answered that a mother with a child below school age should work fulltime or parttime individual opinion about fathers is an indicator that takes value 1 if the child answered that a father with a child below school age should work parttime or not at all panel c shows the results of the incentivized coordination game for every question it displays the percentage of children who answered that it is fairly appropriate and the percentage of children who answered that it is appropriate the social norm about mothers indicates the share who answered that it is at least fairly appropriate that a mother with a child below school age works parttime or fulltime the social norm about fathers indicates the share who answered that it is appropriate that a father with a child below school age works parttime or does not work at all panel d shows the share that contributes at least occasionally to each domestic task the variable counterstereotypical behavior is the average of small repairs and grocery shopping for girls and the value of cleaning for boys panel e shows the expectations of respondents in 20 years time regarding fertility and labor market participation the variable counterstereotypical expectations is 1 if a girl does expect to work fulltime and have children the standard deviation is given in brackets column displays a wald test on gender differences and the respective standard errors are in parentheses p 01 p 005 p 001 4 report pvalues providing control of the familywise error rate these are implemented using the rwolf2 command in stata using our preferred specification and clustering while relying on 100000 bootstrap replications figures and tables research project the impact of public policies on the cognitive and noncognitive development of children principal investigator lídia farré main goal of the project the objective of the research project is to determine the effects of different public policies on the cognitive and noncognitive development during childhood methodology the researchers will visit the school and will ask all students attending 1 st and 2 nd grade of compulsory high school 6 th and 7 th grade to participate in a survey as well as some mathematical quizzes the participation in the study will last approximately 30 minutes risks and benefits of participation students will participate in a study that will help to improve the design of public policies to acknowledge their participation in the study students will receive a voucher to be exchanged at a local stationary store participating students must exert some effort in particular they must concentrate and focus on a screen for 2030 minutes in order to complete the exercises as such there is a slight risk of fatigue in addition some children might find it stressful to solve simple mathematical quizzes under time pressure privacy to protect privacy childrens responses will be kept completely anonymous any results that will be shared or made public will refer only to the aggregate responses of children attending multiple schools and will be done so in a completely anonymized way as such it is impossible to identify neither the school nor the municipality voluntary participation participation in this project is completely voluntary we will inform students that their participation is voluntary and that they can withdraw at any time without having to justify their decision we will also request the explicit consent by the teacher if you have any questions about the study please contact lidia farré • shouldnt work at all 2a • should work parttime • should work fulltime • i dont know • i prefer not to answer 3 imagine a family with a child who is still too young to go to school what do you consider the best way to organize their family and work life • the mother stays at home and the father goes out to work fulltime • the mother works parttime and the father goes out to work full time • both the mother and father go out to work fulltime • both the mother and father work parttime • the father works parttime and the mother go out to work fulltime • the father stays at home and the mother go out to work fulltime • i dont know ii contest in this part of the study you have to complete three different tasks to win points the number of points you win will depend on the number of correct answers you give when completing the tasks before beginning each task we will give you instructions on how you can win points test run in the three tasks you will be asked to add up 3 numbers to get used to doing the task on the computer you will now be allowed a 30second test run during the test run you cannot win any points 1 task 1 individual task you will now have 2 minutes to do the sums for each sum you get right you will win 1 point if you make a mistake no points are deducted this task is called the individual task task 2 quiz you have been put in a group with three boys or girls from your class as in task 1 you will have 2 minutes to do the sums the boy or girl from your group that correctly solves most sums will receive 4 points for each correct answer the rest of the group will not win any points this task is called the quiz we are now going to ask you some more questions about yourself please answer these questions sincerely and remember no one will know how you chose to respond paternity leave permit may have the power to foster gender convergence in the future by shaping the gender norms of the next generation and thus removing a key obstacle on the path to gender equality note students at one of the schools answering the questionnaire 3 are restricted to the treated cohort and column and to the control cohort column shows the did estimate for the respective variable using equation in the main text and controlling for birthdate fixed effects and school fixed effect the respective standard errors are in parentheses p 01 p 005 p 001 for online publication only appendix a additional figures and tables appendix b information letter and questionnaire appendix b1 information letter provided to the parents dear families we would like to inform you that the school of your child will participate in a project led by researchers from universitat pompeu fabra universitat de barcelona and universität würzburg these researchers will visit the school within the next few days and will ask all students enrolled in 1 st and 2 nd grade of compulsory high school 6 th and 7 th grade to participate in a survey as well as in some mathematical quizzes the researchers will compensate all participating students with a voucher of a symbolic amount that can be exchanged at any abacus stationary store nearby the answers of the students to the survey and the mathematical quizzes will be anonymous the researchers will share with the school only the aggregated results once the project is finished i confirm that • the information about the research project has been read to me • i have been able to ask questions about the project • i have received enough information about the project i understand that my participation in the project is voluntary and that i can withdraw from it at any time without having to justify my decision i give my consent to take part in this research project yes no i attitudes we are now going to ask you some questions please answer these questions sincerely we want to know what you really think no one will know how you chose to respond there are no right or wrong answers 1 read the following statements and say whether you strongly agree agree neither agree nor disagree disagree strongly disagree a a mother who goes out to work can have just as good a relationship with her children as a mother who does not go out to work b it can be bad for a child under the age of 3 if her mother goes out to work c when a mother spends the whole day out working family life can suffer d having a job is fine but what most women want is to form a family and have children e taking care of the home and family can make a woman just as happy as having a job f both partners should bring money into the home g the man should be the breadwinner while the woman should take care of the home and family h when a woman earns more than her husband there are certainly problems i both the mother and father should take leave from work for a few weeks after the birth of their son or daughter 4 how do you think most people in your class responded to the following statement the man should be the breadwinner while the woman should take care of the home and family if you answer correctly you will win 5 points strongly agree agree neither agree nor disagree disagree strongly disagree iv outcomes we are now going to ask you some questions about how you see yourself in the future please answer these questions sincerely and remember no one will know how you chose to respond if the job youd like to do is not on the list write it here v demographics 1a what year were you born in 1b what month were you born in january february march april may june july august september october november december 1c what day were you born on between the 1 st and the 12 th between the 13 th and the 23 rd between the 24 th and the 31 st

economists whose research aims to provide answers to the global labor market challenges of our time our key objective is to build bridges between academic research policymakers and society iza discussion papers often represent preliminary work and are circulated to encourage discussion citation of such a paper should account for its provisional character a revised version may be available directly from the author

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background maternal depression is a serious public health issue 1 depressive symptoms are marked by an extended sense of sad mood loss of interest tearfulness sleep problem restlessness irritability appetite disturbance and even suicidal ideation or attempt 2 previous studies suggested that depressive symptoms were found among about 10 to 20 of mothers and such symptoms can last for several months or even a year 3 depression can happen at any time throughout the whole pregnancy process from early pregnancy to even after delivery 4 antenatal depression itself is an important risk factor for maternal depression at other timepoints for pregnant women as well 4 furthermore due to the unique role of mothers in caring their babies previous studies suggested that children of depressive mothers are three times more likely to develop serious emotional problems 56 a lot of studies have been done to explore the risk factors of maternal depression 7 8 9 recent reviews suggested that sc is a protective factor for individuals mental health status and it could also significantly reduce the risk of antenatal and postpartum depression 10 11 12 sc is defined as features of social organization such as trust norms and networks that can improve the efficacy of society by facilitating coordinated actions 13 it comprises two components namely the cognitive sc and the structural sc 14 the cognitive component refers to the internally subjective aspects of sc that reflect peoples perceptions on the level of interpersonal trust sharing reciprocity and other norms 1516 the structural capital is more about the externally objective dimension and is featured by behavioral expression of social network and individual participation or community activities 17 till date most studies on sc are crosssectional in nature in order to further explore the relationship between sc and maternal depression a followup study design was used in the current study with both cognitive and structural sc being measured at the individual level the fourth baby boom period in china is approaching as a result the number of women at their reproductive age is increasing rapidly with an increment of about 2 million per year 18 and a majority of them are the first generation of babies after the onechild policy was implemented 1819 this group is very special in the sense that they are the only child in their family and as a result most of them are spoiled moreover a majority of them will be parents for the first time in the traditional chinese culture parturients should practice sitting the month after their delivery a period where they should stay at home for about one or two months to recover after they discharge from the hospital 2021 this practice could bring huge changes on the life style and social environment of the parturients during this period on one hand primiparas need to adjust to get used to their new roles as mothers meanwhile the focus of the whole family will suddenly move towards the baby these changes could result in a sudden drop of emotional support perceived by the primiparas 22 on the other hand sitting the month will limit their social activities which will ultimately lower their perceived social support levels 1922 other than the abovementioned issues a lot of families nowadays also need older generations input while taking care of the babies this arrangement has a high potential to cause crossgeneration conflicts which poses another potential risk towards the primiparas thus it is not surprising that about 50 to 75 of primiparas in china had reported experiences of unstable mood accompanying by different level of physical symptoms in china 19 to the best of our knowledge there are very few studies had explored the relationships between sc and maternal depression at different timepoints throughout the pregnancy progress using a sample of chinese primiparas the current study aims to answer the above question through a followup study design we hypothesized that sc level of primiparas will be negatively correlated with depression among chinese primiparas 10 11 12 methods study design this study was conducted from march to december 2016 in the largest maternity hospital in zhejiang province china new mothers admitted to the hospital during the recruitment period were approached by the study team those who were willing to join the study were then assessed for their eligibility to be included in the study the primiparas should meet the following criteria 1 in the hospital for the prenatal checkup 2 18 years old and above 3 being pregnant for 3036 weeks pregnant 4 planning to give birth and attend postpartum follow up at the hospital 5 willing to participate in the study 6 literate in chinese and 7 not suffering from cognitive deficit a total of 450 subjects were recruited for the current study and following informed voluntary written consent the participation was voluntary and they were informed that refusal to participate will not affect the care they are going to receive from the hospital this study was approved by the ethics board of the hangzhou normal on 4th march 2016 data were collected at three different timepoints 1 t1 while the participants were recruited at their 3036 weeks of pregnancy in the antenatal clinical t2 at their 2nd or 3rd days in the wards after the delivery t3 at week 6 to 8 after the delivery in the postpartum examination clinic to enable easier administration the survey was built using an eplatform and a qr code was generated by scanning this qr code using their mobile phones individuals could access to the full questionnaire including the sociodemographics and scales to evaluate primiparas sc and depressive symptoms and they could choose the time point and completed the survey on their mobile phones this qr code was stuck onto the casebook of each participant enabling the data collectors to easily identify the participants while they were in the hospital in the case that the primiparas forgot to fill in the survey phone calls were made by the investigators to remind them to scan that qr code to fill in the equestionnaire more detailed information regarding the measurement scales were included as the following measurements sc was measured by the chinese version of sc assessment questionnaire 23 this questionnaire was developed by zhou and colleagues among chinese primiparas based on the world banks sc assessment tool and bians chinese position table 2425 more details of the cscaq and tis development and validation could be found in zhou et al 23 the cscaq can be used to measure primipraras sc on both the cognitive and structural domains cognitive sc includes the social trust and social reciprocity subscales the st subscale has 8 items in total and it measures the generalized trust among colleagues neighbors and strangers the sr consists of 7 items and assesses the reciprocity among colleagues neighbors and strangers the score for each item varies from 1 to 5 the structural sc domain covers social network and social participation sn is assessed using bians chinese position table 25 which considers chinese social characteristics by position generator method sn includes network diversity score ranging from 0 to 20 upper reach ability score ranging from 0 to 95 and network range score ranging from 0 to 94 the sp has 11 items covering the activity types motivation and involvement the items of activity types and motivation were graded using a 5point likert scale while involvement was coded with 0 and 1 since the internal measurement units are not uniform the standardized score of sn and sp were used higher score represents higher sc level the cronbach α of cognitive and structural sc dimensions of cscaq were 0773 and 0902 respectively in the previous study 26 depressive symptoms were measured by the chinese version of edinburgh postnatal depression scale the scale consists of 10 items with 4 alternative answers for each item the score for each item varies from 0 to 3 with a maximum score of 30 27 cepds has been tested and validated among chinese pregnant women before 28 compared to the diagnostic and statistical manual of mental disorderiv diagnosis of major depression as reference cepds demonstrated good reliability with a cutoff point score of 9 and above 27 this scale has also been used in other chinese studies and showed high reliability in measuring prenatal and postnatal womens depression 2930 in the current study following the evidences a cutoff of 9 was used to indicate the status of having depressive symptoms statistical analyses data were entered through epidata 31 and analyzed by spss 200 we firstly described the sociodemographic characteristics of the sample the participants were divided into two groups based on epds scores the depression group and the nondepression group the sc was compared between these two groups using t tests separate binary logistic regressions were conducted to assess the relationships between sc and depression at each of the three timepoints with the cepds score being the dependent variable and sc factors being the independent variables the covariates in every regression included age district education level character planned pregnancy incoming per month delivery by cesarean section relationship with husband relationship with parentsinlaw and sleep in all regressions a twoside pvalue below 005 was treated as statistically significant results sample characteristics a total of 450 primiparas were eligible to participate in the study at t1 and 41 were excluded from the study representing a response rate of 911 of the 41 primiparas who were excluded 25 refused to participate and 16 intended to give birth in other hospitals at t2 and t3 376 and 288 primiparas completed the followup assessment respectively in the end 288 primiparas who completed all the three interviews were chosen as research subjects in this study the demographic characteristics of primiparas are presented in table 1 more than half of the subjects aged between 18 and 29 years old and 611 were from urban areas more than half of the subjects had undergraduate college degrees and above and 635 described themselves as introverted most of the subjects had a planned to pregnancy and 583 had a monthly income of more than 4500 cny one third of participants were delivered by cesarean section after delivery most of the subjects reported good relationships with husband and parentsinlaw 153 of them suffered from poor sleep after delivery prevalence timing of depression and sc figure 1 shows 25 the prevalence of depressive symptoms of the participants 25 of the primiparas were found to have antenatal depression at t1 135 and 208 showed symptoms of postpartum depression at t2 and t3 after delivery respectively the mean scores of the epds were higher at t1 and t3 and lowest at t2 the scores of cognitive and structural sc at three different timepoints are presented in figs 2 and3 and the curves had opposite directions comparing to that of the epds in fig 1 the mean scores of sc at different timepoints are presented in table 2 the cognitive and structural sc levels were lower at t1 and t3 and highest at t2 association between sc and depression the association between sc and maternal depression are presented in table 3 the st sr and sp mean scores of depression group were significantly lower than those of the nondepression group at all three assessments the mean sn score of the depression group was significantly lower than that of the nondepression group at t1 after controlling for the exogenous variables adjusted associations between antenatal depression and sc are displayed in table 4 the model at t1 shows that st and sn were significantly negatively correlated with antenatal depression the model at t2 shows that st was significantly negatively correlated with postpartum depression the model at t3 shows that st and sp were significantly negatively correlated with postpartum depression discussion depression status of primiparas this study showed that the prevalence of depressive symptoms of chinese primiparas throughout the pregnancy process following a v shape and this is similar to findings from a previous study in greece 27 the highest prevalence of epds was at t1 and the lowest one at t2 epds scores at t1 were higher than t3 however studies in china tended to pay more attention to the period of 68 weeks postpartum among the primiparas 31 32 33 we observed that the prevalence of depression was highest at the late pregnancy among our primiparas sample this suggested a potential high costeffectiveness if timely interventions could be implemented at this timepoint in the literature one cohort study by milgrom et al in uk showed that depression scores were 672 at 32 weeks of pregnancy and higher than 584 at 8 weeks postpartum 34 richedwards et al found that the prevalence of depressive symptoms was 9 at midpregnancy and 8 at postpartum 35 these are similar to our study 36 a 6month followup study indicated that 68 women were found to have postpartum depression at the end of first week after delivery and the prevalence were 125 90 and 49 at the end of the first third and sixth month respectively 27 josefsson et al showed that the prevalence of depressive symptoms during late pregnancy was 17 in the maternity ward 18 68 weeks postnatally 13 and 6 months postnatally 13 in sweden 37 sc status of primiparas results from the current study suggested that the sc scores throughout the pregnancy process followed an upsidedown v shape the curve is opposite to that of the edps scores and consistent with our hypothesis firstly the highest social capital level was at t2 usually primiparas will leave the hospital 3 to 5 days after delivery thus they were still in the hospital at the 2nd to 3rd days after delivery during this period their husband or parents will carefully take care of them and their relatives friends and colleagues will visit them and give red envelopes or newborn gifts 38 those social interactions and gifts might give them with greater support and comfort moreover the happiness levels for new mothers are normally very high at this timepoint due to the joyfulness they would experience in the sense of having a baby secondly the results shows that sc level went down after they discharged from hospital and moved to a relatively low level at t3 in china primiparas should be confined at home for one full month of convalescence after discharge from the hospital 39 this practice might change their normal social environment moreover their psychological status might be largely affected by the attitude of family caregivers 38 similar finding was reported by another study in china suggesting that pregnant women had the highest level of social support level at 1 week postpartum and decreased afterwards 38 the government needs to encourage regularly postpartum visits to improve the primary maternal health management and doctors can provide them with more professional supports thirdly it was beyond our expectation that the lowest sc level was at t1 it may be the case that pregnant women at this timepoint are too clumsy to move around 4041 this will limit their social activities and result in loss of facetoface contacts with friends and acquaintances 4041 another important finding of our study is that the two curves of structural sc had larger fluctuations than curves of cognitive sc through interviews with primiparas we learnt that a lot of the primiparas took part in training such as parenting classes provided by the maternity hospital before delivery to better prepare for their coming firsttime delivery through these activities they got the opportunities to meet doctors nurses and other new mothers and make friends with others as a result to expand their social networks 38 their activity levels and networks would decline rapidly during the confinement however st and sr which require longer time to develop would stay according to the blood relationship culture in china they specifically trust their family members 42 during the whole pregnancy and childbirth period their family members will always be around with them although their cognitive sc level might be influenced by the confinement it is still more stable than the structural sc influence of sc on antenatal and postpartum depression among primiparas this study examined the effect of sc on antenatal and postpartum depression among chinese primiparas and analyzed the relationship between sc and maternal depression in previous review articles few studies carried out follow up research on the association between sc factors and maternal depression among pregnant women 4344 our study includes four dimensions of sr st sn and sp from cognitive and structural sc at the individual level and is also the first followup study in china with such a sample size the current study found that the nondepression primiparas had higher sc levels than depression group at all three timepoints similar findings were also reported in a longitudinal study by lamarca et al 43 they investigated the associations between individual sc and consistent selfrated health in women between the first trimester of pregnancy and six months postpartum and found that the good selfrated health group had higher scores of sc than the poorer group 43 in our study st had strong association with depression at all the three timepoints this is consistent with previous studies fujiwara and kawachi found that perceptions of higher levels of cognitive sc were associated with lower risks of developing major depression among adults during the 23 year followup 44 a prospective analysis also indicated that low interpersonal trust appears to be an independent risk factor for newonset and longterm depression in south korea 45 a potential explanation could be that interpersonal trust can provide emotional support to help primiparas to deal with their stress 4546 it is interesting that sn has a strong association with antenatal depression at t1 and sp was associated with postpartum depression at t3 it may be the case that primiparas will get to know new mothers and nurses and expand their networks through pregnant women school activities as mentioned above these networks can provide emotional support for primiparas on delivery and parenting and it might also be beneficial to reduce their depression level and needs to be further verified 34 after delivery appropriate participation is helpful to alleviate depression but the traditional confinement seems to be an obstacle for sp armstrong and edwards showed that mothers in the pramwalking intervention group improved their fitness levels and reduced their level of depressive symptomatology significantly more than the social support group 47 zhang also indicated that taking active parts in social activities if physical conditions permit can reduce postpartum anxiety 48 there are a few limitations for the current study firstly this study examines the relationship between sc and peripartum depression at only three timepoints 3036 weeks of pregnancy 23 days and 68 weeks postpartum so we might miss the highest point of depression and the lowest point of sc level if the survey can be extended to include the first trimester to 6 months after delivery and the results of observation might be more intact secondly epds is a selfreport tool to measure mood and there might overpathologising motherhood 49 this phenomenon has a certain effect on the results thirdly although a followup design was used regression analyses to explore the relationships between sc and maternal depression were conducted separately at each timepoint fourthly given that the study participants were from zhejiang province this might limit the generalization of the study findings lastly personality of primiparas was measured by a single question would you describe yourself as extroverted or introverted without using a scale more studies are still needed to confirm whether the findings from the current study will be applicable nationwide conclusions we examined the association of sc and maternal depression among chinese primiparas the prevalence of epds had a v type distribution and sc form an upsidedown v the two curves of structural sc had larger fluctuations than curves of cognitive sc the sc level of depression group was lower than nondepression group at all three timepoints st and sn were significantly associated with the depression of primiparas at t1 st was associated at t2 and st and sp were associated at t3 for future maternal health education and promotion programs more attention could be given to sc improvement in the community pregnancy health care management additional file additional file 1 survey data data of social capital and depressive symptoms scores were collected among chinese primiparas at different timepoints from their late pregnancy to postpartum qy critically reviewed and edited the manuscript and provided comments for its further improvements bdz hc wjw and lh participated in data collection and analysis and lwx、ly revised the manuscript and made valuable suggestions on scholarly writing all authors contributed to and have approved the final manuscript competing interests the authors declare that they have no competing interests

background this study aims to investigate the association between social capital sc and depressive symptoms among chinese primiparas at different timepoints from their late pregnancy to postpartum methods a total of 450 primiparas were recruited for the current study the assessments were conducted at three different timepoints t1while the participants were recruited at their 3036 weeks of pregnancy in the antenatal clinic in the maternity hospital in zhejiang china t2at their 2nd or 3rd days in the wards after delivery t3at week 6 to 8 after the delivery in the postpartum examination clinic sc was measured by the 29item sc scale while depressive symptoms were measured by the edinburgh postnatal depression scale the relationships between sc and depressive symptoms were explored separately at each of the three timepoints results the prevalence of depression among the primiparas was 25 at t1 135 at t2 and 208 at t3 respectively however the score of sc and its components at three timepoints followed an opposite v direction with the highest score at t2 following by t3 and t1 at t1 the analysis suggested that depressive symptoms among the primiparas were negatively correlated with their social trust and social network levels at t2 only social trust was negatively associated with depression while at t3 it is social trust and social participations that were significantly negatively associated with depression conclusions sc was associated with depression at all three timepoints during and after pregnancy more attention should be given to sc in the maternal health promotion programs of community pregnancy health care management

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introduction e epidemic caused by the human immunodeficiency virus represents a global dynamic and unstable phenomenon e nature of its occurrence in the different regions of the world depends among other determinants on individual and collective human behavior 1 it is estimated that there are currently around 367 million individuals worldwide infected with hiv in brazil between 2007 and june 2016 there were 136945 reports of infection by the virus 2 however in latin america the annual number of new hiv infections among adults has remained stable since 2010 e number of people recently infected with hiv is significant in latin american countries like bolivia venezuela guatemala and brazil 3 incidentally just seven countries accounted for 90 of new cases of hiv infection in 2016 in latin america of these around one half of new infections occurred in brazil followed by mexico with 13 3 over the last ten years the prevalence of hiv has been identified in some regions of brazil as either in decline or remaining steady however the north and northeast regions still exhibit a linear growing trend among the most noteworthy is the state of maranhão located in the brazilian northeast where there was an increase of 822 in the detection of the disease between 1980 and 2016 there were 16255 new cases of aids reported in this state 4 e detection of new cases of hivaids has focused on specific groups of people with potential exposure to the virus particularly through unprotected intercourse such as sex workers men who have sex with men bisexuals people with multiple partners and alcoholdrug users 256 studies show that mens sexual proclivities have been responsible for the increased vulnerability to hiv e data support the assertion that bisexual men and msm individuals are more likely to acquire hiv than heterosexual men 7 8 9 understanding the factors related to peoples sexual orientations which are responsible for the increased risk of hiv infection is important for the advocacy of minority groups and combating the hivaids epidemic in addition it is important to understand these associations based on a social determinants of health model as a theoretical framework in brazil one of the sdh models adopted in healthcare studies related to people with hivaids is the one proposed by dahlgren and whitehead 10 is studys objective is to analyze sociodemographic and behavioral factors associated with vulnerability to hiv according to sexual orientation materials and methods is is an epidemiological observational and retrospective study using an inductive approach is strategy also referred to as inductive reasoning starts with the observations and theories proposed based on observation inductive research involves the search for patterns based on observation and the development of explanations for those patterns 11 ethical approval was obtained from the appropriate research ethics committee under opinion no 1502368 e participants in this study comprised individuals over 12 years of age male and female with an active sex life in the twelve months preceding the survey e research was conducted between january and may 2017 at a healthcare unit specializing in stiaids in the city of imperatriz maranhão in northeastern brazil e city of imperatriz has a population of approximately 252320 and is the second largest in the state of maranhão in terms of population and also socioeconomic political and cultural factors having a medium human development index of 0731 nevertheless the municipality still faces problems in terms of the rates of illiteracy and basic sanitation 1213 is information bears witness to the social setting of the city in which this study was conducted data collection for this study was performed by nurses previously trained for hivaids testing and counseling in the period between 2015 and 2016 consultations lasted approximately twenty minutes per participant and took place in a private setting in the aforementioned period the number of people contacting the health service was 4006 irtyeight people who did not satisfy the previously stipulated criteria were excluded from the survey our data collection tool was developed based on new hiv case records as recommended by the brazilian ministry of health based on the data collection tool we establishedas a variable outcomesexual orientation followed by hivpositive status e predictive variables investigated were then divided into sociodemographic factors and clinical behavioral characteristics according to the sdh model the sociodemographic conditions in which people live have an impact on their health e main social determinants of health are food education health services environment and the current socioeconomic situation in the analysis of the findings we considered the two concentric layers of sdh proposed by dahlgren and whitehead as follows layer 1 and layer 2 14 e data were transferred to microso office excel 2010 and the analyses were performed in the statistical package for the social sciences® program version 220 to begin with the kolmogorovsmirnov test was applied for a weighting of the normality of the quantitative variables following this procedure homoscedasticity was determined via levenes test pearsons andor fishers chisquare tests where applicable were used to test the association between the variables considering a significance level of 푝 005 furthermore the odds ratio was calculated to estimate the effect of the variables evaluated multiple logistic regression was performed to test independence between outcome and associated variables e following outcome variables were chosen hiv infection and independent variable are sociodemographic factors and risk behaviors for hiv infection according to the stated sexual orientation to determine independent risk factors for infection logistic regression analysis was used e variables were selected from the simple multinomial logistic regression based on the wald test e variables were introduced into the multiple model one by one in accordance with their statistical significance observing the following blocks of variables the first of the variables was sociodemographic then followed by the behavioral ones variables remained in the multiple model when they were significant or when they were fitted to the model with regard to sex and age results msm and bisexual individuals as far as msm and bisexuals are concerned the predominant profile was male aged over 30 unmarried black brown eighthgrade education or higher and the majority were engaged in some form of paid activity in this study we observed that msm and bisexual individuals were more likely to be male unmarried and have attained a higher level of education on the other hand this stratum was less likely to be in the over30 age group as shown in table 1 msm and bisexual individuals were more likely to have multiple sexual partners as shown in table 2 in the group consisting of msm and bisexuals infected with hiv all were male aged under thirty unmarried blackbrown skin color with eighthgrade education or higher and some form of paid employment in the group consisting of msm and bisexuals hiv infection was most likely to happen to males and also those with some form of paid employment on the other hand the lowest chances of hiv infection prevailed among married people and among those who stated they were of white skin color as shown in table 3 a er multivariate analysis adjusted for sex and age the behavioral variables were found not to be associated with hiv infection in the group of homosexualsbisexuals msm and bisexuals were more likely to have multiple sexual partners we did not find in either group a statistically significant association between being hivpositive and a history of sexual abuse heterosexual individuals with regard to the participants we noted a predominance of males and those who declared themselves to be heterosexual participants ages ranged from 12 to 84 years of the heterosexual individuals analyzed the majority were male aged over thirty single black or brown with eighthgrade education or higher and some form of paid employment we found that heterosexual individuals in the last 12 months were less likely to present with an sti to have used alcohol or to have used condoms we also found that heterosexuals are less likely to be infected with hiv predominant among hivpositive heterosexuals were male subjects aged over 30 married blackbrown with eighthgrade education or higher and having some form of paid activity among heterosexuals the under30 age group was the least likely to contract an hiv infection while those with low levels of education were more likely to be infected with hiv e result of the multivariate analysis adjusted for age and sex was that heterosexuals were more likely to use illicit drugs and less likely to have used condoms in the last 12 months and were also less likely to be hivpositive among heterosexuals those who did not smoke cigarettes were more likely to be infected with hiv as shown in table 3 a er multivariate analysis adjusted for sex and age heterosexuals who did not smoke cigarettes presented a higher risk of being hivpositive when separately analyzing the two sexual orientation groups regarding the occurrence of hiv infection from the clinical andor behavioral variables it was observed that heterosexuals who did not use the cigarette in the last twelve months had a higher chance being infected with the hiv virus as shown in table 3 26 condom use among latinos depends on factors such as religion relationship stability level of education and income for example heterosexual latino men prioritize the use of condoms in extramarital sex as opposed to when having sex with their wives 29 brazilians concept of masculinity is that the man is the provider so to guarantee his health is to guarantee the familys subsistence 30 moreover historically the northeast region of brazil has presented negative indicators related to women such as machismo domestic violence and femicide 31 accordingly we believe that this finding reflected a gender issue furthermore between heterosexual partners there is a persistent feeling of trust satisfaction and intimacy for which reason condoms may not be used in sexual relationships 3233 ese issues partly explain the fact that in our study heterosexuals used condoms infrequently but at the same time had less chance of contracting hiv another peculiarity observed in the group of heterosexual participants was that those who did not use tobacco were more likely to be infected with hiv ese results suggested that infection in this group does not seem to be influenced by smoking aside from reflecting the reduction in the number of smokers among the brazilian population in recent years due to the increase in the price of cigarettes prohibition of tobacco advertising and the elimination of indoor smokingdesignated areas 3435 despite the greater use of illicit drugs and less frequent use of condoms heterosexual individuals were less likely to be infected with hiv according to this study in fact there are associations between the use of illicit drugs and the risk of contamination with hiv 3637 we believe that our findings derive from the fact that most subjects from the group of heterosexuals who participated in the study are monogamous limitations is research had a number of limitations e interviews conducted by the nurses addressed questions about behavior andor clinical characteristics relating to sexuality erefore because this is an intimate or embarrassing subject for some people there is a probability of incomplete or false responses additionally we did not analyze the association of the findings of hiv serology with information about participants monthly income andor socioeconomic classification or purchasing power another point of view must be introduced as a potential limitation participants from this study were people who of their own volition approached an hivaids healthcare service in other words they are well aware of their risk for infection people who do not seek or have not yet sought health services may present different or even more worrying behavior we emphasize that it is pertinent to conduct new studies with different methodological approaches andor scenarios on this issue as a way of helping health practitioners in primary healthcare because as we gain more knowledge on the peculiarities among heterosexuals 2015 594 of hiv infections occurred among homosexual or bisexual men moreover this finding amounts to another global characteristic namely that the number of infections among msm individuals is on the rise 415 we believe that this finding resulted indirectly from an increase in the demand for counseling and testing services by the male population e national human health policy promoted by the brazilian ministry of health in recent years may also have contributed toward these findings due to epidemiological changes actions geared toward prevention health education and health promotion are important especially when targeted at men who have sex exclusively with men and those who have sex with both men and women as these groupsin addition to being in the minorityindulge in behavior that makes them prone to hiv infection 267 in this study multiplicity of partners was predominant among homosexuals and bisexuals however in this group those who were married were less likely to be infected with hiv while heterosexuals were less likely to have stis or use alcohol ese findings support the current discussion in several studies on the vulnerability of homosexuals and bisexuals in general unmarried individuals have exhibited a higher propensity to contract hiv infection 16 17 18 however previous studies conducted in brazil china and canada have shown that unmarried msm individuals and male bisexuals are more vulnerable to hiv infection 19 20 21 some authors have already pointed to the issue of multiplicity of partners among homosexuals and bisexuals since it increases the chances of contracting stis 2122 in this study the majority of msm subjects and bisexuals had some form of paid employment and were in a lower age bracket than heterosexuals is could partly explain the purchase of sex or drugs that favor the practice of unsafe sex both areas are problematical in brazil since they are unregulated andor socially unacceptable activities similarly unprotected sex can be influenced by alcohol use as it predisposes users to have multiple sexual partners and dispense with condoms 2324 among people living with hivaids alcohol use can be a negative predictor for issues such as adherence to antiretroviral therapy risky sexual activity and systemic physiological effects 25 us among those who are hiv positive combating this habit is a priority for viral suppression 26 moreover msm and bisexual men have a greater number of sexual partners or even a greater propensity to indulge in sexual intercourse with strangers 2728 both of these situations may increase vulnerability to hiv infection in addition regarding the use of drugs it is possible that this is the result of a regional cultural paradigm people in the lgbt group are using both lawful and illicit drugs more frequently heterosexual individuals although heterosexuals in this study demonstrated reduced risk factors for hiv infection they were also less likely to use condoms in latin america the main way hiv is propagated is through unprotected sex msm and transgender women being the most affected homosexuals and bisexuals it will be possible to improve the epidemiological evaluation of hivaids and propose healthcare measures for the general population conclusions heterosexual individuals were less likely to use condoms to be infected with hiv to have stis and to use alcohol than homosexuals and bisexuals msm and bisexual individuals were more likely to be male unmarried have a higher level of education and have multiple sexual partners when compared to heterosexuals data availability e data used to support the findings of this study are included within the article conflicts of interest e authors declare that there is no conflicts of interest regarding the publication of this paper

objective to analyze sociodemographic and behavioral factors associated with vulnerability to hiv according to sexual orientation method is is a crosssectional study conducted using data on 3818 people in the city of imperatriz brazil during 2015 and2016 e surveys questionnaires addressed sociodemographic and behavioral variables for the data analysis association chisquare test and strength of association odds ratio were observed a significance level of 푝 005 and adjustment for age and gender were taken into consideration results a substantial portion of the sample stated they were heterosexual 888 ese individuals demonstrated a lower chance of hiv infection 푝 0001 sexually transmitted infections 푝 0001 alcohol use 푝 0001 and condom use 푝 0001 compared to men who have sex with men andor bisexuals in this group a er adjusting for confounding variables the factors associated with hiv infection were being male 푝 0001 unmarried 푝 0001 having completed higher education 푝 0001 and boasting multiple sexual partners 푝 0001 conclusion behavioral and sociodemographic factors of vulnerability to hiv are predominant among men who have sex with men andor are bisexual

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introduction peer victimization is a developmentally salient interpersonal stressor that refers to the experience of being the recipient of peer intimidation and harassment or being the target of physical social emotional or psychological harm from a peer 1 as a form of aggressive behavior there is the risk of escalation and if the victimization is repeated and intentional and there exists an imbalance of power between aggressors and victim it takes the form of bullying 2 school victimization is an important social problem with serious shortterm consequences for victims physical and psychological health and negative longterm effects on their future psychosocial adjustment as adults the cumulative consequences of early victimization may emerge at later points in childrens school careers and have been well documented 34 in cases where the victimization becomes chronic the consequences may have an even greater effect on childrens achievements and learning 5 peer victimization has been associated with emotional and behavioral problems over time that are beyond the childs preexisting difficulties 6 with children who are victimized at risk of a wide range of adjustment difficulties that include selfharm 7 loneliness social avoidance selfblame 8 suicide ideation 9 anxiety and depression 10 social maladjustment loneliness 11 lack of close peer relationships 12 low selfesteem 13 poor physical health psychosomatic complaints behavioral dificulties and deficient emotional adjustment 1314 other important findings show there is also a potential significative impact on adult adjustment outcomes 15 such as problems with doing housework and managing money 16 trouble forming new social relationships less social support poorer family functioning and lower levels of education 17 early diagnosis and timely treatment of these problems at a young age will not only improve childrens adaptation at school and their emotional and social development 18 but will also help to prevent their impact in later years preschool and peer victimization most of the research about peer victimization has focused on middle childhood or adolescence beyond the home school is usually the main environment where childrens difficulties with social interactions with their peers can be primarily detected and subsequently assessed by adults and professionals 18 during preschool and kindergarten children learn how to build and maintain friendships and they form opinions about who they like or dislike and they establish groups of consistent play partners 19 experts on child development strongly agree on the importance of acquiring cognitive and socialemotional competencies at the preschool stage 20 the manifestation of peer victimization in the preschool years is similar to that of schoolage children in many ways but differs in others depending on the childs development of social cognition 21 younger students usually tend to resort to physical aggression possibly because they have not yet developed the required sophistication of verbal or social skills to obtain what they want with maturation children start utilizing verbal skills to engage in more subtle forms of verbal aggression 2223 andor develop more complex social skills such as assessing and manipulating social situations and they can also engage in indirect forms of aggression 22 for these reasons it is important to study peer victimization from preschool ages prevalence and measure although the most severe forms of peer victimization seem to have reduced in many countries over the last few years 24 efforts to detect and prevent this type of aggressive behavior in schools are still essential there is an abundance of largescale studies on elementary and high school children 1225 but less studies have been carried out on preschoolers the literature shows that even at these early ages peer victimization occurs frequently and is associated with poor psychosocial wellbeing 26 ilola et al 27 found a 4 sixmonth prevalence of frequently bullied children as reported by the parents of a sample of 931 4yearolds who attended pediatric checkups in another large populationbased study of 5to 6yearolds that used reports from parents and teachers a similar 4 of the children were victims 10 a problem like peer victimization which remains hidden in most cases requires information from as many sources as possible the strengths and difficulties questionnaire 28 is a tool with good psychometric properties that is widely used to screen for psychiatric disorders and its version for children aged 3 to 4 years old has been utilized at preschool age 2930 the sdq has versions for parents and teachers to account for discrepancies between informants since different informants observe childrens behavior in different settings 31 parents and teachers are the ones who spend most time with preschool aged children given the preventive aim of early detection both reports are indispensable under the attribution bias context model 32 which posits that informant discrepancies are indicative of crosscontextual variability in childrens behavior and informants perspectives on this behavior the sdq includes a peer problems scale which contains a specific item for peer victimization if this questionnaire is widely used and registers the presence of peer victimization it could be used for identifying early warning signs of problematic behaviors indicating that the child is a target of aggressive victimization behaviors and for studying their risk factors a warning sign is an observable manifestation that hints of the existence of something that may impact negatively on the person in this case peer victimization risk factors to help designing preventive and intervention strategies against peer victimization it is crucial to determine the risk factors that enable the prediction of the onset of victimization to facilitate an early identification of infants at risk of becoming victims 33 several longitudinal studies have identified factors that relate childrens personal characteristics and their home environment with an increased risk of being victimized 34 the socialecological model posits that peer victimization involvement is determined by the multiple systems in which youth are embedded 35 first introduced in the late 1970s 36 this ecological model was initially applied to child abuse 37 and subsequently to youth violence 38 the model explores the relationship between individual and contextual factors and considers violence as the product of multiple levels of influence on behavior 39 understanding how these factors are related to peer victimization is one of the essential steps in the public health approach to preventing this violence 40 the first level of the ecological model focuses on the intrinsic characteristics of the individual that might increase the likelihood of their either becoming a victim or a perpetrator of violence and the guiding assumption for these factors is that victimized children behave in ways that invite or reinforce attacks against them 41 it has been suggested that aggressors often have a positive outlook on the use of violence to solve problematic situations or get what they want 42 this follows the theoretical assumptions underlying proactive aggression bullies can be quite adept at identifying victims who will either not retaliate or will be ineffective in their efforts to retaliate making them more desirable targets 43 some children may have temperamental behavioral and cognitive characteristics that evoke aggressive behavior from others and make them more prone to victimization among children and adolescents longer exposure to peer victimization has been associated with higher emotional sensitivity anger fear and internalizing and unstable affective temperaments 44 similarly psychopathology may contribute to victimization over time internalizing and externalizing behavior problems are associated with victimization 45 however prospective studies of young children that examine such antecedent effects are largely lacking 46 few studies have tackled the cognitive characteristics of the victimized children in a brazilian sample was found that 10to 11yearold child peer victims presented difficulties in executive functioning and showed lower cognitive flexibility 47 previous studies regarding victimization and ethnic andor racial differences have produced mixed or inconclusive results 48 some studies report that minority youth are more likely to be victimized 49 whereas others have found that the percentage of immigrants and the racial variability of school children do not seem to be risk factors for being victimized 50 the second level of the ecological model is related to the family environment and explores how proximal social relationships for example relations with family members increase the risk of victimization 40 the impact and relation of family characteristics as risk factors of victimization has gained increased attention in recent years it has been shown that parental characteristics and adverse lived experiences may have an impact on children facilitating peer victimization 51 several studies have shown that peer victimization is associated with inconsistent punitive hostile andor abusive parenting high negative expressiveness and high levels of family conflict or violence 5253 also children growing up in low or mean socioeconomic status families are at increased risk of victimization 54 furthermore victims from schools in lowses communities or with a large proportion of students from lowses families suffer worse longterm mental illness as consequence of the victimization compared to victims from richer families 54 additionally severe prenatal family adversity significantly increased the risk of peer victimization at school 55 also children whose relatives were abused during childhood have an increased risk of being bullied which may indicate an intergenerational transmission of maltreatment 56 last parental psychopathology also affects the childs risk of being victimized through complex pathways such as genetic neurobiological and social ones 57 purpose of the study the present investigation is based on the premise that childrens behavioral attributes and family factors contribute to their victimization and has the aim of identifying the children with an increased risk of becoming a victim at the youngest possible age to facilitate timely prevention of the problem awareness should be raised about how the instruments at use allow us to identify the problem and the characteristics of the identified children to determine their usefulness in screening for peer victimization 58 using a prospective longitudinal design the present study seeks to contribute new knowledge about the early individual and family risk factors of being peer victimized during the preschool period and seeks to obtain an estimate of the prevalence of these warning signs of peer victimization at 4 to 5 years old using a widely used screening instrument in alignment with bronfenbrenners ecological model 36 35 individual and family factors were initially selected to identify which were the most predictive of peer victimization selection of the final set of risk factors was made through a predictive modelling approach materials and methods study design and procedure the data was part of a largescale longitudinal study of behaviour problems in preschool children from age 3 who were screened for behaviour problems and followed up annually until age 9 the twophase design used involved selecting first a random sample of 2283 children from the census of inschool 3yearold preschoolers in barcelona during the 200910 academic year the sample size was determined so that the study was able to detect associations between exposure to different risk factors and the presence of psychopathology equal to or greater than or 20 accepting an alpha risk of 5 and a statistical power of 80 epidemiological studies indicate that the prevalence of psychopathology in children and adolescents of the general population is approximately 15 60 likewise a multiple correlation between covariates of 04 is assumed some corrections were applied to the obtained sample a correction for homogeneity of children within the same classroom increasing the sample by 20 b correction because double stage design it was established that screening would classify children into two equally sized groups because only 30 of the group of children with negative screening will be followed it is necessary to proportionally increase the initial number of children to be recruited and c correction for attrition due to refusal of the school to continue participating and due to refusal of subjects assuming 50 of families will leave the study exclusion criteria included the child having a generalized developmental disorder the parents having reading problems or not understanding neither spanish nor catalan languages and having planned a move outside barcelona all the parents of the initially selected pupils were invited to participate in the study from which 1341 families agreed to participate there were no sex or socioeconomic differences between those who agreed to participate and those who declined although more participants than refusals attended private schools the second phase of the sampling consisted in a screening of behavioral problems carried out using the sdq conduct problems scale 28 plus four symptoms of dsmiv oppositional defiant disorder not present in the questionnaire to ensure the presence of children with behavior problems in this second phase all of those who screened positive for behavioral problems and a random sample of around 30 of children who screened negative were invited to continue the final second phase sample included 622 families no differences were found on comparing participants and refusals either by sex or school type the families were interviewed at the school interviewers were previously trained and were blind to the childrens screening group the teachers were asked to complete the questionnaires before the end of the academic year the fig 1 shows the sampling procedure the research project was approved by the ethics commission on animal and human experimentation from the autonomous university of barcelona the parents of the participants children were informed and gave written consent to participate in the study instrumentation outcome measures at ages 4 and 5 strengths and difficulties questionnaire for ages 34 28 for parents and teachers it is a screening questionnaire for behavioural and emotional problems applied for the purposes of this study when the children were 3 4 and 5 years old item 19 picked on or bullied by other children coded as 0 not true 1 somewhat true 2 certainly trueanswered by parents and teachers was selected as outcome we conceptualized that if parents or teachers scored 1 or 2 on this item at both followups at ages 4 and 5 this would be a warning sign for investigating the childs possible victimization that is if the problem as reported by any of the informants was sustained over time the case would be considered as victimized good psychometric properties in the sample have been reported 61 with cronbachs alpha 73 for parents and 82 for teachers at age 3 and slightly better values for ages 4 and 5 predictive measures at age 3 child behavior checklist 62 it is a questionnaire of behavioral and emotional problems reported by parents through 100 items with 3 response options internalizing and externalizing empirical scales plus the dsmoriented scales depressive anxiety developmental attention deficithyperactivity and oppositional defiant problems were used for the analyses higher scores indicate higher symptomatology behavior rating inventory of executive functionpreschool version 63 it is a standardized questionnaire that assesses behaviors reflecting executive functions in daily life in preschool children the instrument consists of 63 items on a 3point scale two dimensions which may be associated with social problems inhibit and emotional control were used and higher scores indicated greater difficulties teachers answered the questionnaire when the children were aged 3 good psychometric properties have been reported 64 childrens aggression scale 65 it is a questionnaire that assesses aggressive behavior with 22 items on a 5point likerttype scale the total score of the teachers responses was used as a global index of aggressive behavior higher scores indicate greater aggressive behavior childrens behaviour questionnaire for ages 37 years 66 it is a questionnaire that measures reactive and selfregulative temperament with 94 items answered by parents on a 7point likerttype scale ranging from 1 to 7 the 3 broad dimensions of temperament negative affectivity effortful control and surgency were considered higher scores indicate more marked traits the reported psychometric properties are good 67 schedule for risk factors 68 it is a computerized structured interview conceived as a compendium of the potential areas of risk of psychopathology that should be evaluated in children demographic information including ses 69 pregnancy events early development and history of abuse suffered by family members were used for this analysis these risks factors were registered as presentabsent as reported by parents the reported psychometric properties are good 70 alabama parenting questionnaire for preschool 71 it was used to assess parenting practices it contains 24item which measures three dimensions of parenting positive discipline techniques inconsistent parenting and punitive parenting two additional scales extracted from the evaluation des pratiques educatives parentalespreschool and primary school form 72 norms and autonomy were added to the instrument with the same response format in the original epepppsf items assessing rules and autonomy emerged as two separated factors and jointly with items assessing positive parenting emerged as a secondorder factor of support the authors also found low but significant positive correlations between these three measures and desirable traits in the childs personality in our sample an exploratory factor analysis for categorical items conducted with mplus81 showed that the 9item and 2factor model with geomin rotation for norms and autonomy items fitted better than a 9item and 1factor model scree test based on eigen values also supported the retention of two factors all items had salient loading in the expected factor moreover in our sample a confirmatory factor analysis conducted with mplus81 for the whole set of items that is considering a 33item and 5factor model showed acceptable fit all factor loadings being at least moderate and statistically significant as expected the higher values for factor correlations were found between norms autonomy and positive discipline techniques for all five measures used in the present study higher scores indicate higher parental practices in the direction of the label of the scale adult selfreport 73 it is a questionnaire of dimensional psychopathology for adults aged 1859 it contains 126 items and was answered by the mothers dsmoriented scales were analyzed higher scores indicate higher symptomatology second column of tables 1 and2 show the cronbachs alpha values of the measures in the sample statistical analysis the software used for statistical analysis was stata 15 for windows to reflect population prevalence the analyses were weighted by the inverse probability of being selected in the second phase of the sampling design a twostage modelling procedure 74 was used to determine the best predictive model of 4to 5yearold warning signs of peer victimization from the 35 predictors preselected at age 3 according to the literature first several independent binary logistic regression models were estimated grouping the predictors by content because of the large number of predictors included in this first stage the false discovery rate 75 was applied to control the type i error and to know which predictors remained significant after correction second predictors with an fdrcorrected significance pvalue below 10 were selected and a backward stepwise binary logistic regression model was conducted predictors from this model with pvalues below 05 were used to calculate the area under the roc curve which indicated the proportion of correct predictions of warning signs of victimization achieved with the selected predictors auc values above 75 are usually considered as indicating a good prediction capability this final model included as covariates parents and teachers answers to item 19 of the sdq at age 3 to adjust the oddsratios of victimization at baseline the predictive capability of the model was calculated through pseudor 2 76 and translated in terms of ordinary r 2 using the same authors approach since no crossvalidation weighted commands have been developed for stata the final predictive model was validated using a repeated random subsampling crossvalidation procedure 77 which produces a summary measure of loss of prediction the hosmerlemeshow goodnessoffit test was verified for each logistic model and the absence of outliers and influential observations was also confirmed 78 results a total of 602 children were available at age 4 and 577 remained at age 5 participants and dropouts at age 5 were statistically equal in sex but participants had a higher socioeconomic status than dropouts parents information was obtained from mothers fathers or both with a mean age of 376 years only 5 out of 577 teachers were male table 3 shows the demographic characteristics of participants for the total sample and separately by absencepresence of victimization warning signs prevalence of warning signs of peer victimization according to the answers given to sdqitem 19 by the 577 participants remaining in the study at age 5 and applying our definition of warning signs of peer victimization the parents reported warning signs at one followup for 159 of preschoolers and at both followups for 30 of preschoolers teachers reported comparable results with 164 of children presenting warning signs at only one age and 14 at 4 and 5 years old to minimize lack of sensitivity a child was considered to display warning signs of peer victimization if parents or teachers reported the item positively at both ages 4 and 5 on applying this definition 24 children were classified as displaying warning signs of peer victimization chisquare tests revealed that there were no differences by sex or ethnicity in the prevalence of warning signs of peer victimization but the risk increased as ses decreased initial selection of risk factors of warning signs of peer victimization at 4 to 5 years old table 1 presents descriptive statistics for the individual characteristic predictors for children with and without warning signs of peer victimization separately the last three columns show the results of the first stage of the modelling procedure consisting of the estimation of several independent logistic regression models to predict warning signs of peer victimization at 4 to 5 years old four individual attributes showed significant oddsratios low or mediumlow ses cbclinternalizing cbcldevelopmental problems and briefp emotional control difficulties after applying the fdr correction to control the increment of the type i error due to the high number of statistical tests performed two predictors remained significant at 10 value ses and briefp emotional control similarly table 2 shows descriptive statistics for the family and early predictors the last three columns show the odds ratios obtained from the first phase of the modelling strategy estimating independent logistic regression models to predict warning signs of victimization at 4 to 5 years old from each set of predictors five significant odds ratios were found economic problems during pregnancy childs early difficulties in making friends a history of childhood abuse among relatives lower norms and higher asrsomatic problems as reported by the mother statistical significance remained below 10 after fdr correction for three predictors difficulties in making friends childhood abuse among relatives and lower norms final predictive model with risk factors of warning signs of peer victimization at ages 4 to 5 the five predictors with fdrcorrected pvalues under 10 were selected as the maximum logistic regression model in the second stage of the modelling procedure to select the significant predictors from these five a backward stepwise regression was applied which retained four significant predictors this final model was adjusted by the baseline presenceabsence of item 19 reported by both parents and teachers the resulting odds ratios show that the risk of presence of warning signs of peer victimization at 4 to 5 years old increased for children with a low or mediumlow ses higher scores in briefp emotional control difficulties in making friends and parenting practices characterized by lower scores in apq norms this final multiple model which included four terms plus the two adjusting terms obtained a pseudor 2 22 which according to 76 is approximately equivalent to an r 2 50 of a linear regression fig 2 shows the corresponding roc curve which reflects the accuracy of these four variables to predict the presence of warning signs of victimization the auc 78 is statistically better than a classification made by chance and could be considered as almost excellent 74 generalizability of the predictive model could be considered acceptable as loss of prediction obtained through repeated random subsampling crossvalidation was only 044 in terms of auc discussion the purpose of this study was to report on the prevalence and risk factors of warning signs of preschool victimization as assessed by the sdq a widely used screening questionnaire reported by parents and teachers according to the endorsement of item 19 42 of 4to 5yearold inschool preschoolers suffered persistent victimization although few studies have reported the prevalence of warning signs of victimization in preschoolers our estimation of prevalence is in line with that reported by previous studies 102779 for children of similar ages in other cultures using one item of a questionnaire for assessing the rates of bullying our assessment of victimization was also done with one item of a widely used instrument the sdq given that aggressive behavior tolerance at any age should be near 0 our results indicating a prevalence of warning signs of victimization in preschoolers equal to 42 showed that from preschool age there was a considerable number of children persistently exposed to being picked on or bullied by other children the adverse consequences of preschool victimization are manifested in children and adolescents in a deteriorated mental health and in the increase of psychosocial problems 80 a variety of individual and family factors at age 3 increased the risk of parents and teachers reporting persistent victimization pertaining to a low socioeconomic status family problems in emotional control early difficulties in making friends and parental practices characterized by lower norms these variables explained almost 50 of the variance of parents and teachers reporting victimization with a near to excellent ability to discriminate between the groups with and without warning signs of potential victimization low ses at age 3 was more frequent in the atrisk group several studies showed that being involved in peer victimization either as victim or perpetrator is more frequent in children and adolescents with a lower ses 1051 families with a low ses might have influenced childrens involvement in victimization in several ways for instance they tend to have a lower participation in social activities 81 in low ses families parents tend to have less involvement in their childrens education practicing low levels of academic socialization with them 82 the educational level of parents was included in the family ses calculation because education not only influences economic status but also reflects noneconomic social characteristics such as intelligence knowledge social norms and values literacy and competence in problem solving 10 all of which are aspects that could be related to child raising behavior and consequently to childrens limitations in the development of social skills and coping strategies 1051 families living with this adversity would need victimization surveillance difficulties in emotional control reported by teachers was found to increase the risk of parents and teachers reporting that the child was being picked on or bullied in other words children who overreact to small problems are explosive have outbursts for little reason are angry or tearful or react very strongly to situations are targets for victimization this result is consistent with previous studies among them a methodologically similar study with parents and teachers as informant and children from 3 to 5 years showing a high association between emotion dysregulation and higher rates of victimization 83 this finding agrees with predictions derived from the social process model 84 because emotional dysregulation may cause peers isolation negative judgments and consequently increase the risk for victimization this path from emotional control to victimization through social processes was also evidenced in clinical samples of children with a diagnose of attentiondeficithyperactivity disorder 85 and children with early manifestations of oppositional defiant disorder 46 both disorders are characterized by high emotional reactivity demonstrating that these disorders at preschool age predicted childrens risk of bullying involvement in the first years of elementary school children who show high emotional reactivity at preschool entry may therefore require special vigilance at school difficulty in making friends was another strong predictor of parents and teachers reporting that the child was victimized from early childhood social competence is an important protective factor for childrens adjustment helping them to engage in shared activities adapt to different situations develop friendships respect turns regulate emotionality collaborate show prosocial behavior acquire a good reputation among peers and be accepted by them 86 social competence is thus a solid base for building good relationships and when this is not well developed the child is at risk of being isolated and isolated children are also a target for victimization 87 regarding parenting practices our results are in line with previous studies supporting that poor parental supervision harsh parental discipline low parental involvement with the child and marital discord are associated with childhood aggression and bullying 88 relatively little is known however about how this influence operates 89 a low parental educational level in social norms may interfere with proper socialization as the child has a deficit in references about how to behave with others and this has also been related to victimization in general population 90 limitations this study has some limitations that must be highlighted we did not include information reported from the child because the young age of the participants and the methods used hampered their participation in older children parents are usually unaware of peer victimization involvement in part because young people do not always divulge their experiences with victimization to their parents 91 whereas parental followup is tighter with preschoolers having no information directly from the child however could mean that some cases of victimization did not come to light a second limitation is that a high percentage of the participant attrition in the followup at age 5 was among low socioeconomic status families this could have resulted in a slight underestimation of the prevalence of victimization another limitation is in reference to the socialecological model because we have not taken into account the community contexts in which social relationships are embedded the classroom environment had a great influence on the amount of victimization reported by peers indicating that there is something in the class context that potentiates or inhibits bullying 92 on the other hand this study also has several strengths peer victimization was assessed using multiple informants and considers risk factors from multiple domains last much of the previous work on victims has been conducted with older children and there are only a limited number of studies that focus on the preschool period conclusions peervictimization starts at preschool ages so early intervention in the preschool context is crucial if we are to break the cycle of victimization in later childhood 34 since both individual and family risk factors of different nature are present in the victims to stop the victimization from escalating requires a broad and multidisciplinary approach implications for school health school is a context where peer victimization may occur and this markedly alters community mental health the development of programs designed to prevent its escalation reduce its negative impact on childrens development and promote adjustment are needed early identification of both the problem itself using screening questionnaires for detecting warning signs and of the problems associated with victimization dynamics may enable closer monitoring of the risk groups as a preventative measure the prevention of victimization and its consequences can be improved by focusing on risk groups at school in early life our results suggest that victimization intervention programs should consider the role of the victims personal characteristics in increasing vulnerability to victimization and the importance of including families in schoolbased intervention programs aimed at reducing the difficulties experienced by victimized children in summary research identifying the risk factors for victimization helps to target interventions to deal with the key factors contributing to the problem thus maximizing their effectiveness 92 data curation joseblas navarro eva penelo formal analysis joseblas navarro eva penelo funding acquisition lourdes ezpeleta investigation meritxell ferna ´ndez nu ´ria de la osa methodology joseblas navarro lourdes ezpeleta project administration lourdes ezpeleta writing original draft joseblas navarro meritxell ferna ´ndez eva penelo lourdes ezpeleta writing review editing joseblas navarro meritxell ferna ´ndez nu ´ria de la osa eva penelo lourdes ezpeleta

school victimization by peers is an important social problem with serious shortand longterm consequences poorly studied at preschool ages which can lead to school bullying without timely intervention longitudinal data was used to determine the prevalence of warning signs of preschool peer victimization and its individual and family risk factorsdata was obtained from 577 community preschoolers school victimization was measured using the strengths and difficulties questionnaire sdq administered to parents and teachers of children at ages 4 and 5 risk factors for the child demographics conduct and emotional problems aggressiveness and the family maternal problems during pregnancy and early development parenting styles adaptive functioning and parents problems were previously recorded at 3 years oldcombined information from parents and teachers showed that 42 of preschoolers presented warning signs of victimization at ages 4 and 5 low socioeconomic status poor emotional control early problems making friends and low level of parenting education in social norms at age 3 predicted later victimization at ages 4 and 5 auc 78 peer victimization affects a considerable percentage of preschoolers early detection may help to reduce the risk of escalation

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from risk economies to the debt crisis the neglected role of imagination following the outbreak of the 2008 global economic crisis governments in the usa and the eu sought to recapitalise their creditbereft financial institutions through an unprecedented shift of privatelyheld risk to individual households the unravelling of the crisis is now familiar by 2007 widespread and largely unregulated and speculative use of financial instruments such as highrisk derivative products had led to increasingly unsustainable levels of toxic debt in the usas financial systems that spread out to the eurozone and across the globe causing a wave of commercial bank bailouts and pushing a number of states to the brink of default on their debts at the same time extensive adoption of fiscal austerity in the eurozone was the dominant and persistent response to the crisis with devastating consequences for countries in the european south sociologists have examined how economic crises are precipitated by the social construction of financial markets demonstrating in particular how risk and debt are coimplicated in the production of economic futures economists on the other hand have focused on excessive risk taking which it has been argued was due to a failure in modelling a failure to understand systemic risk and a failure to estimate well small probability events yet as centeno and cohen demonstrate despite existing models rhetoric of criticism the economic rules of the game remain unchanged importantly for sociologists and social theorists the ability to reimagine ways out of the crisis seems also to have stagnated as gane and back put it neoliberalisms permeating ability invites an opening out to the world in the form of a heightened sensory attentiveness that would enable a different kind of social imaginary a stream of recent edited collections and special issues in various fields of social science has initiated fruitful debate around more imaginative conceptual approaches to understanding the causes of the 2008 crisis one such route has been offered by disciplines outside of sociology and economics which have breathed new life into the study of finance and its vicissitudes of particular relevance to our discussion of the role of imagination is a surge of interest in links between speculative finance and the contemporary world of literary fiction and novels a series of exciting new works demonstrate how the fictitiousness of capital most starkly manifested in the intensified fictionality of modern financial instruments such as the derivative has come to resemble the world of speculative fiction mary poovey a pioneering figure in this genre of work shows how literary forms of writing have mediated and reflected the operations of financial markets organised around credit and debt more recently there have been renewed calls to engage more closely with the social sciences and more daringly with the kinds of culture that feed on and feed into the regime of economic abstraction and financialization in order to explore how financial markets are represented and imagined yet little work has focused on the key role of imagination in constructing specific notions of risk debt and obligation which are implicated in the causes and deepening of the crisis for instance although the imaginative practices surrounding the complex technologysupported products of financial innovation have been mainstreamed our understanding of the resulting social changes and the vocabularies we use to narrate these changes including their implications are lagging behind imaginative financial practices in this article we attempt to provide such a vocabulary by suggesting a potential avenue for mobilising sociological imagination in order to engage with financial crises 1 we argue that enacting the sociological imaginationthe ability to provide critical scholarship aiming to impact on change seems more important than ever today but this can no longer be confined to the realm of sociology works from the broader social sciences and philosophy must be engaged with in order to debate important public issues and approaches from social theory outside of its own boundaries this article seeks to do this by drawing on the works of political philosopher cornelius castoriadis to propose an analysis of financial crises as the manifestation of a specific imaginary social order for castoriadis imagination is the driver of all life and creativity it provides a framework for structuring and giving meaning to actions and behaviours of social collectivities such as organizations and societies it is through a collective sense of imagination that a society is created given coherence and identity and also subjected to both mundane and radical social change we develop these ideas to deepen and extend the notion of sociological imagination in critical social theory by incorporating discursive affective and representational dimensions to theorise its generative role in the constitution of financial crises we propose that the performance of financial and calculative practices reflects dominant images of the future invested with meanings and affects by financial actors it also foregrounds the potential for resistance to such imagesmeaningsaffects by enacting alternative imaginations that is reimagining the nature of debt money and financial institutions the overall goal of this article is thus both deconstructive and constructive first we uncover the imaginary foundations of financialisation and how it has transformed our imaginations in determining who and what is valuable and imaginaries of debt and credit we suggest that the current values encoded in our social imaginary as social forms that characterize western modernity the market economy the public sphere the selfgoverning people among others enable debtfuelled crises and unsustainable fiscal austerity as the dominant response to such crises second we argue that possible responses to financialisation may emerge through a radical reimagining of current arrangements to suggest different ways of organising visavis financial institutions to do so it is essential to introduce the notion of imagination as an enabler for enacting different values the remainder of this article is organised as follows the next section discusses debates on imagination which as we argue focus problematically on a dichotomy between rationality and irrationality we then draw on castoriadis to address the shortcomings of existing approaches and move beyond such hierarchical dualisms we propose a framework that unpicks the role of imaginary conditions of risk and debt relations in the constitution of financial crises in conclusion we argue for a need to recognise existing avenues through which to establish alternative social visions of the future and highlight some wider implications for contemporary social theory the rationality versus irrationality debate in critical social theory as we have suggested so far there has been little direct engagement with the importance of imagination in finance especially around the entanglement of the rational and irrational in the performance of financial markets 2 influential economic sociology studies have long rejected the notion of disembedded rational economic agents arguing that they are situated in complex webs of social ties and personal interactions yet have tended to neglect the role of the irrational and have often failed to grasp the notions of the imagination and the imaginary 3 this is despite nuanced theorisation of the intimate relationship between rationality and irrationality in classic texts and despite contemporary consumerist culture providing plentiful examples for sociologists interested in their inherent interplay in the constitution of social reality and in politics nevertheless in many sociological debates on markets and financial crises irrationality continues to be defined with reference toand juxtaposed against rationality weber considers rationality most notably in relation to technical control through calculative thinking although there are moments where weber admits that the irrational element applies to every experience his texts showcase this relationship between rational and irrational properties most fundamentally in the contradictory coexistence of the endless pursuit of capital accumulation the asceticism of the protestant ethic and the belief in redemption thus weber is resistant to calling a certain type of human action rational and another irrational the good question was not to ask is this action rational … but rather to explore what is the rationality of this action other weberian scholars such as wagner and swidler concur that weber was particularly torn between the progress of rationalisation and its irrational components weber attempted to make intelligible this general process of the rationalization of our whole existence precisely because the rationality which emerges from this process is something specifically irrational and incomprehensible in economic sociology many observers have critically examined the recent crisis in the context of growing financialisation and the economics of risk shifting associating irrationality with financial innovations such as derivative products two relevant arguments are offered in these commentaries one is that increasing systemic reliance on the financialised economy is in itself an outcome of the inherent irrationality of progressively deregulated markets and the opaqueness and complexity associated with these innovations the other argument centres on how the widespread economic assumption of market rationality has been convincingly deconstructed in the wake of the financial crisis for instance engelen and faulconbridge argue that the creditdebt crisis demonstrated how rational and irrational choices alike are mediated by conventions affects and emotions such as greed in complementary and perhaps unintended ways both arguments challenge regulatory systems ability to tame the animal spirits of the market and indebted governments ability to return to fiscal stability through rational regulatory frameworks 4 overcoming the rationalityirrationality dualism through imagination a fruitful way of engaging with the tension between the rational and irrational in financial markets can be found in approaches that focus on the imaginary construction of regulatory logic their insights highlight the role of finance and by extension in their failures in neoliberal markets as possible consequences not of rational or irrational acts but of financial actors drawing on imaginary constructions to create both rational and irrational realities beckert invites us to take the fictions of markets more seriously drawing our attention to the role of present imaginaries of future situations that provide orientation in decisionmaking despite the uncertainty inherent in the situation their power to convince is not bound to rational calculation boden and williams also argue that the dualism implied in the rationalityirrationality debate must be overcome in stressing for instance the hybrid emphasis on the rationally controlled decontrol of emotion to achieve this they call for reanimating the sociological imagination by breathing new emotional life into its classically rationalist bones this call also resonates with latimer and skeggs who posit that any reimagining of the political must go hand in hand with an exploration of imagination as one of the key sites in which all political agendas are played out finally pyyhtinen proposes a restructuring of sociological imagination to account for the material and relational aspects of social life other critiques seek to transcend this dualism by explicitly affording a central role to imagination for instance haiven and haiven and berland discuss financialisation as an outcome of the suppression of imagination haiven sees imagination as inherently positive and belonging to the realm of the creative arts and culture while distinguishing it from the irrational imaginary of capitalist production which is disembodied abstract and divorced from the lived reality of work seen through this lens the global financial crisis is the outcome of the dominance of capitalist irrationality which takes the form of creativity striving for individualism and profit rather than real imagination working toward the common good hence for haiven it is the suppression and financialisation of imagination that corrupts and undermines the reproduction of our own lives as we become increasingly overworked privatised alienated and wrapped in debt in this way capitalisms inherent and recurrent crises are externalised onto individuals and communities such nuanced links between finance and the imagination can be traced as far back as marxs own discussion of fictitious capital which established a close relationship between rationality imagination and speculative futures 5 marxs insight perhaps captured most closely the futureoriented role of the imagination in his discussion of irrational longings and desires that perpetuate market disequilibriums he explicitly recognised links between imagination and the production of a certain type of capitalist rationality when writing about the imaginary appetites that replace real needs with fantasy caprice and whim leading to excessive consumption and alienation from the products of ones work bryan and rafferty show how a more nuanced view of imagination may illuminate the practices of financial actors in the years preceding the 2008 crisis they discuss how the imaginative acts of financial inventors decompose social practices and events into attributes that can be objectively measured of probabilities that can be calculated and prices configured and for all of which enough players are willing to take each side of a contract to form a market specifically the authors investigate the social impact of the imaginary of derivatives and how derivatives embody an imminent development in capitalist markets and society at large their thesis is that a regulatory focus is insufficient to prevent failures triggered by risktaking practices insofar as it fails to address the social and imaginary constitution of those practices in this vein there have been increasing calls warning sociologists not to give disciplinary support to the imprecise imaginary of a contemporary reformism which regards the return of the state and of regulation as a panacea for crisis our article responds to these calls by developing a framework that challenges the view of an inherently positive imagination becoming financialised hence rather than merely discussing an imagination crisis or a financialised imaginary resulting from a bureaucratic capture it proposes that the unfolding of financial crises should be considered as an imagination struggle between different actively instituting types of dominant and alternative imaginations in so doing it foregrounds the interplay of the financial and the social in the field of the imaginary to achieve this we now turn to the work of political philosopher cornelius castoriadis reengaging sociological imagination through cornelius castoriadis castoriadis offers a sociologicallyoriented view of human imagination as a structuring force for all meaningful activity his theory of imagination is underpinned by three core concepts representation signification and affect these serve as a generative matrix for the creation of meaning for individuals and societies and can be summarised as follows first representation is understood as a nonfunctional ability to produce new images that are not reflections but conditions of reality second signification is positioned as openness and indeterminacy of meaning as a conscious act of breaking with inherited closures of meaning third affect encompasses the desire to take ownership of indeterminacy enabling the discovery of new meaning and potentialities as it plays a key role in connecting the psychic with the socialpolitical it reenforces a sociological view of imagination in offering a radical theory of imagination born out of the desire of the psyche and necessity castoriadis powerfully elucidates how the actual institution of society is made possible representable and thus meaningful as we have shown elsewhere he achieves this by rendering meaningless any dichotomies between the representational and nonrepresentational rational and irrational and affective and discursive insofar as rationality is inherently constituted through imagination in a process of instituting once a type of rationality has been instituted it becomes a measuring stick for various other significations and meanings rendering them rational irrational or even arational in other words specific rationalities are socially instituted norms and practices that govern social life and cannot exist outside collective rationalities simultaneously by emphasising the creative function and potentiality of institutions rather than their role in reproducing structures and meanings castoriadis shows that the historical world is the world of human doing the conceptual innovation of a productive imagination positioned at the centre of the social creation process has powerful implications for understanding how the social world is organised as joas reviewing castoriadiss work puts it castoriadis is working with concepts of the theory of action that cannot be made to fit the rigid dichotomy of theoretical models of rational action and their normative critique this is because he reconceptualises the entire idea of creative praxis as a stimulus for political action originally conceived by marx through the imaginary this is evident in castoriadiss discussion of autonomy in societys positing of its own laws he uses the example of sophocles antigone to show how autonomous action does not disclose a rationalist view of the world where one persons right collides with anothers antigones notion of right is not simply onesided it is her own this question of taking ownership of ones own moral laws and thus of ones own imagination is key in advancing a sociological imagination its products are enacted though not necessarily determinable and are therefore open to reimagining this view resonates with work by ruth levitas who builds on a long tradition of utopian thinking in political science and philosophy in challenging the dichotomy between real and utopian futures following ernst bloch levitas foregrounds anticipatory consciousness which animates the belief that a different reality and relationship with the future is possible she thus rehabilitates what we can term after castoriadis imaginary strivings importantly this approach contributes nuances to c w millss sociological imagination as a factor in facilitating social change while providing further insights into the unravelling of financial crises specifically castoriadiss antidualistic conception of rationality encompassing irrationality as ir prompts us to discuss financial crisis as an imagination struggle first such a view suggests that imagination plays a subtle yet important role in structuring the creation of rationalities which underpin not only financial institutions but also the regulatory systems aiming to control them second this view corresponds with millss own claim that sociological imagination enables us to grasp history and biography and the relations between the two within society in particular castoriadian imagination illuminates the mechanics of such relations between history and biography revealing the relationship between a society instituting and being instituted or in his own words of history made and of history in the making the ways through which this process of imaginary constitution is achieved comprises as we have seen representation signification and affect crucially imaginary constitution suggests that collective entanglements of images discourses and affects may give rise to new representations and resignifications they may institute new rationalities which may escape dominant imaginations the next section considers how this might be possible focusing on the fiscal aspect of financial crises and the constitution of debtorcreditor relations under the influence of financialisation discussion debt and austerity as crises of imagination having discussed the role of imagination in creating dominant conceptions of rationality and its failures we now consider the consequences of the crisis experienced in the repositioning of social and political relations in terms of individual and sovereign debt this development of debt relations has important material political and ethical implications stemming from the financial crisis which can be viewed as a struggle between different types of imagination on the one hand there is the imagination embodied in rational and calculativecontrolling practices of financial markets which corresponds with the instituted imagination in castoriadiss framework this type of imagination reflects the dominant form of discursive significations with its concomitant representations of the future and corresponding affects yet although instituted imagination leads to a specific markettype rationality it also coexists with another type of instituting imagination enacted by all social doing including acts of both identification and disidentification with the potential to drive alternative visions of the future for instance in the eurozone crisis we can trace the dominant imagination central to the workings of financial markets and institutions as well as their regulatory systems at its root lies a moral imperative to impose sacrifice and punishment for unsound economic practices and to reduce profligate spending while the target of such cuts is invariably the public spending that often benefits the most vulnerable groups such policies are legitimised visavis its citizens as necessary to avert an even bigger crisis of state insolvency this is in fact what weaves together the imagined financial futures by moulding perceptions of risk and debt ultimately leading to a horizon of possibility that is at once dislocated and delimited for example dubois argues that neoliberal economics in the late postcrisis capitalism did not reinvent the relationship of implicated actors with the future but rather extended it the eurozones sovereign debt crisis encapsulated this policy of avoidance to address the causes of financial crises in the most spectacular and profound ways while also echoing the narrative of there is no alternative to austerity on the periphery of the eurozone in effect foreclosing the possibility of imagining alternative futures this foreclosure relied on and served the purpose of suppressing the symbolic and material violence that indebtedness brought to weaker eurozone members yet another type of imagination was also at play acting as an instituting force to enact autonomy through the ability to reimagine given rules and laws and bring about social change such imagination can thus relocate visions of the future back within actors own control by addressing the selfoccultation of societys own power to institute itself reconnecting with the instituting imagination is central to any political project aiming to open up the possibility of a different future it requires actors collectively to recognise their own role in sustaining current financial governance systems and strive for new imaginaries relying both on their embodied collective memory and on reorganising information collection and calculation in the remainder of this article we illuminate this dialectic by focusing on imagination as an interplay of representations significations and affects underpinning debt relations representation debt works on both collectivities and individual human psyches by producing images that are meant to move us emotionally or merely satisfy the voyeuristic viewer rather than providing any factual information indeed as bottici argues on a global scale images dominating media representations of the debt crisis seemed to be chosen on the basis of their ability to affect the publics imagination this was aptly demonstrated for instance in the grouping of indebted economies in the european south and ireland under the zoomorphic terminology of piigs evoking images of sloth excess and impurity and in the narrative of muchneeded reforms that somehow centred on reducing support for the most vulnerable sections of the population absent from such representations were explanations of the reasons for reckless lending by for instance french and german banks to eurozone countries in southern europe and to ireland importantly such practices conjured up a representational gap compounded by financial capitals own optimistic apprehensions of the future these involved positive imagery around market efficiency manifested in triple a ratings of financial institutions right up to the outbreak of the crisis dardot and laval argue that these representations enabled risk to be offloaded in opaque ways for example as securitised debt within financial networks that the new regulatory systems could not reach a dislocated future is also engendered by derivative contracts that rather than simply being ways that individual investors diversify risk serve to reallocate social power and capital thus functioning as imaginary constructs that do real disciplinary work in such ways images of risk and debt move further away from the public and into the private domain in a retreat to the private space while increasing liabilities are transferred to individuals widening the representational gap between experienced consequences and a delayed future thus the opaqueness of and disconnect between the present practices of debt securitisation and risk taking produce financialised imaginaries social life is increasingly defined by debt relations social attributes of debt holders become part of what is cut out and rebranded rewritten as different kinds of financial risk and distributed to classes of security here castoriadiss concept of imagination illuminates how we might intervene by creating alternative images that can be inserted into these dominant representations and alter existing irrationalities thus enabling us to establish a different relationship with the future by repoliticising the present such intervention relies on individuals capacity to respond collectively to debunk false and evoke new images or infuse the old ones with new meanings for instance damasio draws on neurophysiology to show how images of possible future scenarios precede the cognitive processes through which we represent the world and imbue it with meaning in a sense we need to feel and think about the future in order to decide what to do one such example can be found in the occupy movements famous use of the 99 symbol to signify all those affected by the 2008 financial crisisan image that reflects the sense of unity and power felt by people aiming to reverse the distribution of capital in response to financialisation signification applying castoriadiss notion of signification also explains how the postcrisis imagination relied on a variety of discursive means to project an image of the indebted future while closing off all other possibilities a variety of means was deployed discursively to embed such significations of which the dominant one was the morality narrative of deceived big lenders irresponsible individual borrowers and conniving states as sandbu argues this narrative also characterises the approach of lender governments such as germany to dealing with debtor states such as greece and more recently italy however the morality argument is spurious as it cannot on its own sustain the future projected by economic responses to the crisis for instance critics arguing for further market liberalisation often reject the moral ground for austerity arguing for its necessity on the rationalist basis of their own economists utopias another related discursive trope is the debate on the best ways to address the consequences of debt in terms of the inequalities created as captured in the opposition between keynesian and austerian camps in the aftermath of the 2008 crisis the former called for expansionary government spending as a means to overcome the worst effects of the crisis which can be understood in material human terms while the latter insisted on curtailing public expenditure to reduce indebtedness which is often presented as disembodied and abstract remarkably in all these cases the evocative language used to describe the causes of crisis was couched in terms of individual vices whilst solutions were presented as sanitised technical issues with no consequences for human lives the signification gaps between the futures charted by such solutions and the meanings afforded to debt risk and obligation in the present are widened in what cooper calls the delirium of debt reflecting the speculative nature of debt as the future promise of neoliberalism the present is thereby pushed to its ultimate limit insofar as debt must eventually redeem future promises it is not merely promisory or escapist but also deeply materialist that is it seeks to materialize its promise in the production of matter forces and things lazzarato describes this process as debt imaginaries that produce enclosures of a commodified future thus limiting what is possible to imagine yet dominant debt narratives must also be seen as expressions of a struggle between financial and alternative social imaginations which thus remain open to challenge resignification must rely on deconstructing how the present becomes eliminated and revealing the illusory premises of debt futures brassett and clarke show how the act of resignifying the consequences of financial crises for instance portaying home foreclosures and unemployment as traumatic events may strengthen the practical potential of political movements if home foreclosure could be defined as traumatic then victims could potentially claim legal compensation in circumstances where it could be proved the process was avoidable this is very different from a passive reliance on state intervention affect the imaginary construction of debt relations also draws on affect to sustain public narratives and representations the dominant imagination of debt accumulation legitimated lenders disciplining operation in postcrisis greece where debt emerged as a nodal point of signification in relations between the state and its citizens such imagination relied on the pastoral cultivation of a particular ideal ego with which every greek citizen had to identify in order to satisfy the european gaze the big other and be properly readmitted into the eurozone family of normal memberstates lenders and debtors are thereby affectively constituted in different ways excessive risk taking by the powerful is often disguised andor misrepresented as relying on rules while the indebtedness of the relatively powerless is cast in emotive terms as the fault of the individual these discursive strategies are meant to evoke feelings of powerlessness in individuals who are expected to submit themselves to inevitable precarity and impending impoverishment while deflecting their attention from the systemic causes of such outcomes regulatory systems operate in a similarly atomised way in imposing rational rules to control the irrational and irresponsible behaviours of individuals and countries the feeling of being corrupt is then affectively experienced as guilt and shame by individual citizens cast as their own moral failure conversely positive affects continue to animate beliefs in the markets effectiveness and the associated practices of making financial products more complex while banks have again been hoarding capital since their rescue through public funds these arguments point to the struggle of imagination to control the future producing materially felt consequences that exacerbate existing power differentials the imaginary construction of debt relations is a vehicle that carries them to a dislocated future as peebles puts it debt can be seen as a method devised for a debtor to borrow speculative resources from hisher own future and transform them into concrete resources to be used in the present while for creditors current resources are exchanged for speculative future gains debt thus engenders a material as well as temporal link between creditors and debtors with important affective consequences for the regulation of this relationship regulatory and fiscal policies implemented in the aftermath of the 2008 global financial crisis may ultimately lead to a statesponsored debtfare state with fiscal policy centring on suppressing wages reducing working peoples purchasing ability and ultimately affecting their livelihoods health and ability to survive hence the failure of austerity policies adopted by states such as those in the european south should be traced to neither irrationality nor failed rationalities but should rather be seen as reflecting a dominant set of images meanings and affects concerning the future the product of a struggle between different imaginations at work conclusions in arguing for a new conceptual framing of imagination for studying financial crises this article makes three key contributions first we have explained the deeper structuring role of the imagination in financialisation where institutionalised beliefs values and practices of risk taking become coimplicated in the production of dislocated financial futures to illustrate the serious tangible and potentially longlasting consequences of this process we have focused on the constitution of debt relations in the aftermath of the financial crisis arguing that a specific type of dominant imagination was mobilised in order to enforce concrete political financial and fiscal realities using castoriadiss framework we have demonstrated that such material effects are predicated on mobilising images of an everdistant future of prosperity and an increasingly inhabitable present achieved through an interplay of representation signification and affect second we have developed an antidualistic approach that unpicks and rejects a simplistic separation of the rational and irrational as a starting point for explaining crises engaging with a longstanding sociological debate we have argued that the rationalityirrationality relationship in financial markets is much more complex as both are entangled in a process of imaginatively constituted notions such as price and risk as well as debt and obligation rather than being a reflection of economic rationality these notions are complex representations of social forces with political agendas third and relatedly we have approached the financial crisis as an ongoing struggle between a dominant instituted and a suppressed instituting imagination we have argued that these two types of imagination are intertwined and embedded in discursive and affective relationships underpinning constructions of reality such imaginaries are designed to veil the intensity of conflicts between different social groups as manifested in the creation of private and sovereign indebtedness in order to articulate alternatives to the financial crisis it is essential to uncover its imaginary constitution a project which as we have argued must rely on reanimating the sociological imagination our approach has important implications for economic sociologists echoing adkinss thesis that a sociology of debt should not be confined to anthropological analysis of the moral crisis of debt but should also challenge the rational and material underpinnings of debt relations our proposed framework enables a better understanding of how policy interventions that aimed to address the crisis were acted out but also highlights their inherent limitations the very idea of intervening remains ineffective insofar as it subscribes to and perpetuates a neo bureaucratic system our recentring on imagination suggests that governments current regulatory focus serves the growing fusion of private and public realms in financial life promoting a future defined by their own type of imagination such a future relies on specific discursive and affective structures and is grounded in a fantasmatic narrative of independent and observable rules equally applicable in all instances lastly and importantly our perspective challenges critical theorists endorsement of imagination as something inherently positive that needs to be unleashed or simply freed from the grip of financialisation rather we argue for an understanding of imaginations in the plural as intertwined everstruggling and coinstitutive of financial and social futures future research on financial crises should examine more closely the struggles of imagination that underpin a certain politics of crisis in order to shed light on how and where instituting imagination is able to challenge dominant instituted paradigms this project might be especially fruitful in areas such as social movements studies where there is increasing interest in grassroots opportunities and innovative practices found under circumstances of austerity in new ways of coproduction and in new forms of mutual aid to address economic and political crises relying for instance on selforganising imaginaries highlighting the imaginary constitution of financial crises not only exposes some of the overlooked symbolic mechanics of financial markets but also points to ways to pursue alternative radical imaginations that may widen common counterhegemonic horizons of possibility imagination bottici cogently discusses this distinction arguing that it corresponds with that between reason and rationality 4 the critical analytical response to the 2008 crisis has focused largely on the role of lax regulation that indulged derivativeissuing amongst trading institutions framing the crisis as an expression of excess and calling for a stateled return to moderation however most regulatory initiatives on derivative trading have been at best modest in their impact on curbing the lack of transparency in trading practices with relevant institutions continuing to hold opaque financial positions sociology 48 1024 1038 wagner p a sociology of modernity liberty and discipline london verso white h c where do markets come from american journal of sociology 87 517547 notes 1 despite recent calls to reengage with c w millss sociological imagination to our knowledge the concept has not been directly engaged to deal specifically with the constitution of financial crises

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introduction on march 11 2020 the world health organization declared the coronavirus disease 2019 to be a pandemic as of december 11 2020 johns hopkins university reported 101027 confirmed cases of covid19 and 918 deaths in denmark since march 11 2020 denmark was shut down as a basic means of limiting peoples exposure to the virus including closures of schools workplaces fitness centers and sport associations and social gatherings of more than 10 people these decisions will inevitably affect peoples regular leisure physical activity in denmark pa plays an important role in many peoples everyday life and is often carried out as organized sport in sports associations or fitness centers the beneficial effects of regular pa on many health outcomes are wellestablished pa has an important role in reducing impact of the covid19 pandemic by having a positive effect on immunity inflammation and viral respiratory infections pa can also reduce stress and depression which may increase during the pandemic due to health threats job loss reduced income and isolation from social contacts due to the multiple benefits of pa it is important to sustain an active lifestyle during the covid19 shutdown nevertheless the world has struggled with a physical inactivity pandemic for several years affecting especially those from lower socioeconomic groups and younger and older adults it is argued that the covid19 pandemic will increase those struggles and persist long after the world has recovered from the pandemic several studies from different european asian and american countries haveto some degreeinvestigated the impact of the covid19 shutdown on pa behavior all reported some form of decrease in pa from before to during the shutdown whereas three of the studies also reported no change or an increase in pa for some specific groups this may be due to poor measures of pa and small sample sizes as two of the studies did not report a specific pa measurement tool used and one of the studies only included 267 participants seven of the studies were crosssectional using retrospective and selfreported online surveys to measure pa whereas one was a longitudinal study that used devicebased pa monitoring some studies assessed the impact of the shutdown on pa for different age groups whereas one study only focused on older adults none of the studies seem to have included people younger than 18 years old none of the studies were conducted in denmark or any other scandinavian country the lack of scandinavian studies and studies on specific age groups suggest a gap in the literature this gap is important to fill to understand the worldwide consequences of the pandemic on pa behavior as well as the specific consequences for the danish population this supports political leaders in their decision making on covid19related restrictions and helps public health officials to make recommendations for pa during a shutdown the aim of this study was to investigate the impact of the shutdown on danish citizens leisure pa throughout different stages of life this is done by analyzing retrospective and selfreported data on pa behavior before and during the covid19 shutdown among teens younger adults adults and older adults methods study design and recruitment the present paper is a crosssectional study conducted in denmark between april 3 and 15 2020 during the covid19 shutdown april 15 was chosen as the end date for the study because several restrictions from the danish government were eased from that day on april 3 2020 the study announced a press release including a link to an online survey to recruit participants the survey was also distributed through facebook by posting a link to the survey on the university departments facebook site and afterward sharing that link in different facebook groups on linkedin and through the universitys work mail the facebook post was boosted 1 time after 1 week to gain further reach the study was advertised as a survey on peoples movement behavior during the covid19 shutdown it was explicitly mentioned that everyone no matter how much or how little previous or current pa experience they had could participate in the study inclusion criteria were people over the age of 15 years data collection the online survey was created in surveyxact based on a standardized danish national pa survey repeated every fourth year which asks citizens about their pa behavior at workschool during leisure time and about active transportation for this study only questions about leisure pa were assessed the survey started and ended with a range of background information on age gender education ethnicity job situation and living situation this was followed by a range of questions on the participants general leisure pa behavior before and during the covid19 shutdown how much time did you usually spend on pa per week before the shutdown how much time per week do you spend during the shutdown on pa how often were you physically active before the shutdown how often are you physically active during the shutdown it was clearly stated not to include active transportation housework or strenuous work the participants were also asked what types of pa have you done on a regular basis during the last 12 months before the shutdownduring the shutdown the survey included examples of leisure pa other questions were where have you primarily been physically active during the last 12 months before the shutdownduring the shutdown who where you the most physically active with before and during the shutdown have you gained new pa habits during the shutdown last the participants were asked to identify perceived factors important for whether they are physically active during the shutdown to assess contextual factors that may explain a possible change in pa behavior all questions came from the original national pa survey and were adapted to the specific covid19 shutdown the survey took on average 10 min to complete the survey was tested on different age groups prior to its release to ensure that the adaptions were understandable the survey was found understandable by all age groups but feedback from the test respondents resulted in the inclusion of additional response categories to the question on important factors for pa the survey was only available in danish ethical approval participants were given information about the study in the introduction to the survey at the end of the survey participants were able to read additional information on how data were used and stored that they accepted that their data would be used for research purposes upon completion of the survey and that they were able to withdraw from the study at any time the study and its datamanagement procedures were ethically approved by the research innovation organization of the university of southern denmark analysis data were downloaded from surveyxact and uploaded in ibm spss statistics version 25 paired ttests were performed to test for significant overall changes in weekly minutes of pa between before and during the shutdown as well as pa changes for several demographic groups between before and during the shutdown pearson chisquared tests were performed for specific subgroup analyses on the four age groups teens young adults adults and older adults to test for independence at a 005 significance level between the four age groups before and during the shutdown results overview a total of 1347 participants answered the full survey and an additional 455 partly answered the survey all 1802 participants were included in the analysis participants demographics are presented in table 1 the oldest participant was 85 years old and the youngest was 15 years old mainly females and danishspeaking citizens participated in the survey two thirds of all participants lived in large towns and mainly worked at home during the shutdown table 2 displays demographic differences in mean minutes of pa per week before and during the shutdown overall mean minutes of pa dropped 161 from before to during the shutdown of the 215 participants who did not do pa before the shutdown 512 started doing pa during the shutdown and 71 of those doing pa before the shutdown stopped doing pa during the shutdown comparing participants educational level the highest drop in pa was found among those with the lowest education whereas the smallest drop was registered among those with the highest education although it was not significant those living in a large city had the smallest decrease in pa compared with those living in a village or countryside age specific differences teens teens experienced the largest decrease in mean minutes of pa per week those who did pa 5 times per week or more increased by 191 during the shutdown whereas those who rarely or never did pa increased by 718 before the shutdown more than half of the teens did outdoor activities and almost a third did street activities and team ball games primarily in sports associations during the shutdown more than half still did outdoor activities but only a fourth did street activities and only 70 did team ball games activities during the shutdown were primarily done at home or in public before the shutdown pa was mostly done with friends but was during the shutdown mostly done alone or with family teens perceived most factors important for whether they are physically active during the shutdown only 85 identified no factors younger adults younger adults experienced a decrease of 213 in mean minutes of pa per week younger adults who did pa 5 times per week or more increased 91 during the shutdown and those who rarely or never did pa increased 226 during the shutdown primary activities before the shutdown were outdoor activities street activities and team ball games during the shutdown team ball games dropped to 13 whereas 634 did outdoor activities before the shutdown pa was mostly done with friends or alone in sport associations or fitness centers whereas during the shutdown it was mostly done alone in public and at home the greatest factors important for whether they were physically active during the shutdown were that they missed what they used to do and felt that they did not have access to the right facilities adults adults experienced the smallest decrease in mean minutes of pa per week those doing pa 5 times or more per week increased by 443 and those who rarely or never did pa increased by 382 adults mostly did outdoor pa before and during the shutdown pa was done in public or fitness centers before the shutdown and was done in public and at home during the shutdown most adults did pa alone or with friends before the shutdown during the shutdown most adults were still doing pa alone whereas almost half did pa with their family those who lived with their partner and children experienced the smallest decrease in minutes of pa per week whereas those living with their partner experienced the largest decrease finally 264 of the adults did not identify any factors important for pa but almost every third respondent missed what they used to do or felt that they did not have access to the right facilities older adults older adults experienced a significant decrease in mean minutes of pa per week and over a third were rarely or never physically active during the shutdown before the shutdown older adults primarily did outdoor activities and a third did gymnastics in sports associations and fitness or private centers during the shutdown most older adults did outdoor activities such as walking in public and gymnastics at home before the shutdown pa was primarily done with friends and alone during the shutdown more than half of older adults did pa alone and over a third did pa with family members furthermore a third of the participating older adults stated that they did not gain any new pa habits during the shutdown 330 said that they missed what they used to do and 279 felt that they did not have access to the right facilities discussion the study revealed a decrease in mean minutes of pa by 161 from before to during the covid19 shutdown this finding is worrying given the beneficial effects of regular pa on many health outcomes and its important role in reducing the impact of the covid19 pandemic it is particularly alarming that 71 of participants who did pa before stopped doing pa during the shutdown one study by olsen et al finds that only 2 weeks of a marked reduction in pa among healthy individuals had several crucial health consequences although it is difficult to predict the longterm health implications due to decreased pa following an pandemic such as covid19 previous research on the 2011 earthquake and tsunami devastating east japan reports a lasting decrease in pa over 3 years following the disaster this suggests that the covid19 shutdown might have longterm consequences for peoples pa looking at the different subgroups the drop in pa was even higher the lowereducated respondents and those living on the countryside significantly decreased their mean minutes of pa per week more than other subgroups these findings are similar to other studies on pa behavior during the covid19 pandemic unfortunately loweducated individuals and residents living in rural areas are those who already are least likely to meet pa recommendations both inside and outside of denmark and therefore should be given special priority in public health promotion during and after the covid19 shutdown the study also found a significant disparity in pa behavior among the different age groups which is supported by previous studies on pa behavior during the covid19 pandemic and discussed in the following teens teens experienced the largest decrease in mean minutes of pa at the same time there was a substantial increase in individuals who rarely or never did pa during the shutdown not doing pa for a longer time in this stage of life is alarming as this is the time when individuals begin to formulate their healthy habits for life a study by maugeri et al finds similar results they use an adapted version of the ipaq questionnaire on a sample of 2524 individuals and find a 344 decrease in mean mets minweek for younger participants the age range of the 21 age category is however not listed in the study and it is therefore unknown whether they included 1518yearold adults the teens were most often active in sports associations together with friends before the shutdown when these facilities were closed more than half did pa at home and alone in fact a third missed what they used to do felt that they did not have access to the right facilities and lacked someone with whom to do pa for young people social interactions with friends significantly influences pa behavior a factor that may have been negatively impacted by social distancing mandates as a result of covid19 younger adults younger adults had a decrease of 213 in mean minutes of pa per week from before to during the shutdown this decrease may be due to their limited abilities to perform their usual pa routines the younger adults were not able to do their usual pa in sport associations and fitness centers together with friends during the shutdown moreover almost half of the younger adults reported that they missed what they used to do and felt that they did not have access to the right facilities this suggests that restricting younger adults abilities to perform their usual pa routines has negative consequences for their pa in line with this a previous danish study found it important for younger adults to have fixed appointments and a fixed timetable when doing pa the study also shows that younger adults to a greater extent seek stability in their everyday life when they experience uncertainties as such younger adults might have felt a lack of certainty during the shutdown making it impossible to do their usual pa routines adults adults experienced the smallest decrease in pa and the number of adults who did pa 5 or more times per week almost doubled being forced to work from home or not work at all may have increased adults flexibility and ability to do pa at different hours previously adults were found to be the age group that at most prefer flexibility to be able to start or continue an active lifestyle additionally adults might not have been forced to make major adaptations to their usual pa habits during the shutdown adults primarily did outdoor pa alone before the shutdown which they continued to do during the shutdown combined with pa with their family in fact those living with their partner and children had the smallest decrease in minutes of pa this is somewhat supported by a study conducted in the uk during the shutdown rogers et al find that families with schoolaged children were associated with doing more intensive pa social support from family members and doing pa together is found to positively influence adults pa behavior and being locked up together may support doing pa in the family older adults globally half of 80yearold and almost a third of 6079yearold adults do not reach the pa recommendations and represent the least active population group in denmark this highlights the severity of the large decrease found in this study and supported by other studies this age group also experienced a 714 increase in participants rarely or never being physically active this suggests that many older adults went from being regularly active during the week to almost no pa as old age is associated with functional limitations and physical health problems maintaining good physical health is important the observed decrease in pa may be due to several factors related to older adults older adults were the largest group that did not gain any new pa habits during the shutdown this suggests that older adults may have difficulties in adapting their pa habits as they rely more on social support to change and maintain their pa habits furthermore older adults primarily did pa together with friends in public or in sports associations before the shutdown which partly was not possible during the shutdown this is supported by previous research arguing that social interaction is one of the main motivators for older adults to leave their home and participate in activities and that social isolation is associated with higher inactivity strength and limitations this study conducted in a unique situation during the covid19 outbreak offers important insights into the research field of pa behavior this study is the first of its kind conducted in scandinavia and the first to provides contextual data on pa behavior for different age groups a strength of the study is that the survey is based on a standardized danish national survey on pa behavior repeated every fourth year although the national survey has not been validated it has been used numerous times in the danish context throughout the last 20 years making it highly relevant and comparable for this specific study focusing on pa in a danish context it is therefore argued that using an international validated questionnaire for this specific study would be less feasible although using a validated questionnaire may limit measurement error a limitation is the recruitment method which may have limited the representativeness of the study population as the study found an overrepresentation of highly educated females and adults nevertheless 53 of the danish population uses facebook every day with relatively equal distributions of gender and almost all other similar studies have used online recruitment methods such as social media these factors suggest that facebook may be a reliable recruitment method on the contrary because relevance of the survey topic is shown to influence response rates using social media platforms may have caused selfselection bias with an overrepresentation of respondents who may find pa important additionally the survey was only conducted in danish and therefore excluded a range of ethnic minority groups living in denmark the study builds on retrospective and selfreported data on pa which is valuable in obtaining peoples views of their own pa behavior but can be threatened by recall bias with great variance in type frequency and duration of pa although survey questions were on routine pa behavior which may have minimized the recall bias the length of the recall period was within the last 12 months which may be difficult for some to recall we suggest that future studies should obtain data on citizens pa behavior collected prior to the covid19 shutdown to better compare and assess any consequences of the shutdown on peoples pa behavior more so objective data on pa rather than selfreported data on pa prior to during and after the covid19 shutdown would be preferable last because this study included danish citizens over 15 years old caution should be made when interpreting the results of the loweducated participants participants in the age category 1529 years may not have finished a higher education yet as such the loweducated group may not reflect a low socioeconomic group conclusions and perspectives this study reveals that different subgroups of the population already struggling to meet pa guidelines struggled even more during the shutdown the shutdown mostly affected teens and younger and older adults negatively as well as those with lower education and those living in rural areas although shutting down sports facilities and social distancing are important for preventing the spread of the virus it can have negative consequences for peoples motivation and opportunity for pa hence exacerbating peoples physical and mental health in conclusion the shutdown seemed to negatively impact danish citizens pa behavior which is concerning if this decrease in pa will persist and become the new societal norm efforts should therefore be made to help the most vulnerable groups to be physically active during and after the shutdown in fact this study provided relevant information that was used in october 2020 when denmark had to shut down again because of a second wave of covid19 at that time the danish government decided not to close fitness and other private sports centers organized sports in sport associations were also maintained for children and youth up to the age of 21 whereas adults over the age of 21 were allowed to do organized sports together with a maximum of 10 people these decisions might especially help teens and younger and older adults to maintain their leisure pa during the covid19 pandemic and are beneficial to the health of the danish population although the study has several limitations the importance of investigating and learning from this unique situation is argued to outweigh these limitations to spread the knowledge and act more appropriately during future pandemics more studies are needed using objective pa data collected on all age groups as well as different minority groups prior and during the covid19 pandemic to better assess pa change data availability statement the raw data supporting the conclusions of this article will be made available by the authors upon request ethics statement the study involving human participants was reviewed and approved by the research innovation organization of university of southern denmark written informed consent from the participants legal guardiannext of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements 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

objectives because of the covid19 pandemic societies have been shut down changing the lives of citizens worldwide including their physical activity pa behavior this crosssectional study aimed to investigate the impact of the shutdown on danish citizens leisure pa throughout different stages of life 1518 1929 3059 and 60 years methods between april 3 and 15 2020 while denmark was shut down a survey was distributed through online platforms danish citizens 15 years could participate in the study answering questions about their pa behavior before and during the shutdown results the number of total participants was 1802 79 teens 215 younger adults 587 adults and 119 older adults mean minutes of pa decreased 161 from before to during the shutdown teens had the largest decrease in pa 366 followed by older 249 and younger adults 213 low educated 315 and those living in rural areas 309 experienced the largest decrease in pa main factors for not doing pa during the shutdown were that they missed what they used to do lacked social support and did not have access to the right facilities conclusions during the shutdown the danish population struggled even more to comply with national pa guidelines compared with before the shutdown although social distancing and shutting down sports facilities are important for preventing the spread of the virus it can have negative consequences for teens and younger and older adults opportunities and motivation for pa leading to an alarming decrease in pa and consequently will have major public health consequences

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i introduction the past decade has witnessed a national drive to reform and modernise education in china foreign language education particularly english language education is at the forefront of this reform movement the role of teachers in implementing innovation and improving standards has been accorded increasing importance there have been various funded programmes at national and local levels to promote continuing professional development for english language teachers in primary and secondary schools both in china and overseas in this article we draw on the views and experiences of participants from the western provinces of china in an ongoing professional development programme offered at a british university in order to examine the impact of overseas training on curriculum innovation and change in the relatively less developed region of western china in particular we use the diffusion of innovations theory as a conceptual model to understand how innovative approaches to second language pedagogy are being adopted in the participating teachers schools on their return to china in order to contextualise our study we will first present an overview of the policy contexts in china and issues around second language pedagogy and then a brief explanation of the main tenets of the diffusion model curriculum reform in china the first decade of the 21st century can be described as a period of innovation and change in education in china important features of this reform movement are the desire for quality innovation and the gradual move from a deepseated preoccupation with the examination driven curriculum as evidenced for instance both in daily education discourse in china and national policy documents such as the national mediumtolongterm plan for education reform and development curriculum innovation and change in ele are the defining features of this reform movement of particular note are the two new curricula the 2001 national english curriculum standards and the 2003 national english curriculum standards for senior middle school the new curricula emphasise student development through language education with the ultimate goal of developing an overall ability in language use this overall ability in language use includes five components knowledge of the language skills in using the language cultural understanding affective development and cognitive development in other words the new curricula emphasise not only linguistic knowledge but also social cultural and individual aspects of language learning and puts students at the centre of second language pedagogy the new curriculum reflects the gradual shift in second language acquisition and pedagogy over recent decades from a preoccupation with methods of teaching to a greater focus on teaching and learning within this broader perspective the process of learning and the learners role in this process have been accorded due importance the emphasis on competence in language use and the process of learning is also in line with modern innovative approaches to second language teaching particularly communicative language teaching and taskbased language teaching such developments are by no means recent the 1993 national curriculum for english was already explicit in its endorsement of the communicative orientation of ele however innovation particularly in the secondary school sector has often met with resistance and has been the subject of continuing debate the new curricula mark a significant expansion on or a shift of focus from traditional approaches which rely heavily on a pedagogical model of knowledge transmission with teachers closely following a prescribed authoritative textbook on the one hand the nature and extent of teacher receptivity to modern approaches to ele should not be underestimated the vast majority of teachers surveyed in wang welcomed the change in conception and approach to teaching advocated in the new curricula which embed many principles of clt in a study of british council teacher training partnerships with chinese universities gu offers evidence of chinese teachers openness to clt methodologies and a willingness to change and improve their teaching practice almost all teachers participating in the study reported that the training offered by the british specialists had allowed them to appreciate that there were other approaches to teaching but on the other hand departing from more traditional mainstream approach and implementing innovative policy and change in ele inevitably poses many challenges many of the teachers surveyed in wang also experienced feelings of uncertainty and anxiety as is the case with educational change in general in addition implementation of innovation and change entails a good understanding of the change process and enhanced competence on the part of teachers appropriate levels of training and support for teachers professional development is key in fact teacher training is an area given high priority in china various initiatives both at the national and local levels have offered teachers opportunities for further professional development for example short training courses for key teachers organised at the provincial level in the early 2000s and the more recent national drive to train teachers particularly those from rural areas some of these teacher training programmes take place in china often as collaborative projects involving ele specialists from overseas and chinese colleagues others take place overseas for example there have been numerous short teacher development courses of varied lengths for chinese teachers in the uk australia the us canada and new zealand although there seems a lack of published research on them in this paper we focus on one such a programme at a british university context of the present study the british university has been offering threemonth courses for teachers of the course programme consists of the following five components second language teaching methodology language development for the participants a cultural programme placement in local british schools and regular group tutorials in addition the course participants are accommodated in local british host families the rationale for the course design is as follows second language teaching methodology a main component of the programme aims to help enhance participants knowledge and understanding of current theory and practice in ele it uses training materials which have been specifically designed for this target audience and are constantly being updated both to respond to ongoing feedback from participants and to reflect the latest developments and good practice both in education more generally and in the subject area the approach to training like many other teacher education and professional development programmes in the englishspeaking world is largely based on constructivist principles it is studentcentered interactive and inquiryoriented theories are embedded as much as possible in practical tasks and activities to suit the audience the training programme features both experiential learning and loop input in experiential learning trainees or participants temporarily suspend their role as trainee teachers and experience tasks and activities as language students and then discuss and reflect on both the content and process involved loop input is a specific type of experiential teacher training process that involves an alignment of the process and content of learning this flexible and eclectic approach can be characterised as postcommunicative or taskbased defined by cramlap as taking a more constructivist view of learning emphasising personal learning and discovery on the part of the learner with more taskbased collaborative work between learners and a more facilitating role for the teacher the language development sessions and cultural programme complemented by accommodation in host families aims to enhance participants linguistic skills and cultural understanding by immersing them in real life situations the placement week in local mainstream british schools allows the participants to both observe and experience teaching and learning in the classroom in a different educational system it aims to help participants gain an insight into what could be called principles in practice the contextualization of the theories and principles explicated on the course among the distinctive features of the programme are the comprehensiveness of the package the extended authentic immersion experience and the strong academic and pastoral support offered to the chinese teachers by a team of british and chinese colleagues the programme aims to provide an enriching cpd experience for the chinese teachers enabling them to develop not only a rich repertoire of practical pedagogical skills techniques and activities but also a deeper understanding of the rationale behind such practices thus making the link between theory and practice such an understanding is often strengthened by their social and cultural experience outside of the classroom at the time of the present study 15 courses had been completed by just over 500 participants to help understand the impact of the courses on the teachers practice in china we feel the diffusion of innovations model offers a useful theoretical framework which will be discussed below diffusion of innovations the diffusion of innovations model first proposed by rogers in the 1960s and tested in several thousand studies over subsequent decades identifies several dimensions of fundamental importance in understanding the process of change the first concerns the different stages in the knowledge stage individuals are exposed to an innovation but lack information in the persuasion stage they seek more information advantages and disadvantages are assessed during the decision stage where the innovation is either adopted or rejected during the implementation stage the innovation is employed and its usefulness determined finally in the confirmation stage a decision is made to continue using the innovation a second strand concerns the characteristics that determine the success of any innovation relative advantage relates to the extent to which an innovation offers an improvement on what went before compatibility concerns whether the innovation sits comfortably with existing values and practices simplicity and ease of use affect an individuals willingness to adopt the innovation trialability concerns an individuals ability to experiment with the new approach observability refers to the extent to which an innovation is observable to others the model also outlines the different categories of people involved in change innovators are the first to adopt an innovation early adopters are opinion leaders who understand that judicious choice of innovation may help them maintain their social standing the early majority adopts an innovation after varying amounts of time the late majority follows after most people have adopted the change laggards are the last to adopt an innovation two other features of the diffusion model can usefully be mentioned at this point the first concerns the importance of opinion leaders in innovation particularly in peertopeer conversations and peer networks the second concern the role of reinvention as those responsible for implementing change refine the innovation to meet the needs of riskaverse colleagues these various theoretical constructs some of which are largely absent in the literature on innovation in ele will be used to interpret responses to innovation observed in the study schools for instance in terms of the diffusion of innovations model these teachers could be characterised on arrival as early adopters who had been at the persuasion stage at the start of the uk based course end of course evaluations however suggested they had made the transition to the decision phase with positive attitudes towards both social constructivist approaches to learning and modern ele methodologies we were therefore interested to explore the extent to which they could be characterised at varying lengths of time after their return as having progressed to either the implementation or confirmation stages we were also interested in gathering evidence of where their nonparticipating colleagues could be placed along this continuum specifically we sought to answer the following research questions 1 to what extent had the former participants been able to implement innovation and change in pedagogical practice 2 to what extent had they attempted adaptation or localization of the innovative approaches 3 was there evidence of cascading to their nonparticipating colleagues both in their own school and beyond as such our findings are informed by and have implications for theories of the diffusion of change and models of cpd inevitably however our study also aims to contribute to the ongoing debate on second language methodology ii methodology participants were located through a mixture of purposive and opportunity sampling the researchers set out the main parameters we identified schools so as to ensure a good geographical spread and specified that we wanted to involve both participant and nonparticipant teachers as well as head teachers and heads of departments the short time available for fieldwork ten days in total placed important constraints on what we could achieve for this reason operational details were determined by the csc in consultation with local education authorities and individual schools four cites in two provinces and one municipality under direct central government control in southwest china were finally chosen for the field work we used three main methods of data collection interviews focus groups and classroom observations we felt these methods were most suited to the purpose of the present study they would enable us to obtain multiple perspectives from different parties closely involved in the innovation process and to actually observe what was happening in the classroom our aim was to achieve an indepth understanding of the impact of the uk programme on the implementation of curriculum innovation in china insert table 1 about here we conducted open ended semistructured interviews with former participants head teachers and heads of the english departments in schools in zunyi chongqing and chengdu all of whom can be considered early adopters of curriculum reform which includes modern approaches to ele the interviews took place in the respondents offices or the schools conference rooms interviews with former participants and heads of the english departments typically lasted about 30 minutes whereas those with the head teachers lasted between 10 to 15 minutes issues explored during the interviews with former participants included direct or practical methodological aspects of impact conceptual or attitudinal change change in capacity leadership in cpd support for change and evidence of impact on students issues discussed with the heads of the english departments and head teachers covered the following expectations by the department of the returnee teachers contribution by the returnee teachers to cpd in the department or the school the level of support provided to the returnees by the department or school attitudes towards the returnee teachers the management of change and the impact of the overseas training we conducted focus group discussions with two different groups colleagues who had not taken part in the programme from the english departments in the zunyi and chongqing schools and a wide range of former participants from across the region who had responded to an invitation from csc to join us in the following four locations guiyang zunyi chongqing and chengdu issues explored with the nonparticipant groups included their observation of innovation and change in the practice of their overseas returnee colleagues and their own cpd needs and aspirations with the former participants focus group discussions explored issues similar to those covered in individual interviews finally we observed the classes of five former participants and two nonparticipants in the zunyi and chongqing schools focusing on classroom methodology one lesson of each of these teachers was observed which lasted between 4550 minutes by triangulating both the methods used and the sources of information our aim was thus to increase the validity of our findings it was explained clearly to each respondent at the beginning of the data collection session whether it was an interview focus group discussion or classroom observation and that the purpose of the research was to understand what happened when the chinese teachers had returned to teaching after their training in the uk thus we made it clear that our interest was not in evaluating the training programme but rather in trying to understand the impact of the ukbased programme on the teachers practice we were acutely aware of the potential disadvantages of our insider status as researchers trying to assess the impact of a course that we played an important role in designing and delivering in order to minimise the effects of researchers involvement in the design and delivery of the uk course the interviews with the teachers in the zunyi and chonqing schools and focus group discussions with the former participants in chengdu were undertaken by a research assistant unknown to the participants in the study daguo li was responsible for the interviews with the head teachers and heads of english departments and focus group discussions with nonparticipants although at the request of the csc he was jointly responsible with colleagues from the csc for four of the five discussions with the wider groups of former participants similar patterns of responses from all respondent groups indicated that his involvement had not affected participants willingness to comment openly and frankly because the data collection was undertaken by chinese native speakers cultural issues that might have arisen in interviews either in english or with english speakers were avoided focus group discussions and interviews were audiorecorded and transcribed and classroom observations were recorded using field notes data were then imported into nvivo8 for systematic analysis analytical categories were allowed to emerge from rather than being imposed on the data a random selection of the categories were scrutinised by two other researchers independently and there was a general consensus on the categories 2 to ensure the anonymity of participants pseudonyms are used throughout in the present article iii findings the main findings concerning pedagogical innovation in ele are presented under three main headings which relate to the research questions the evidence for the implementation of new ideas on teachers return to china the ways in which new methods were adapted to fit local expectations and the extent to which these innovations impacted on colleagues who had not participated in the overseas courses implementation curriculum reform in china is clearly influenced by social constructivist principles including an emphasis on studentcentred and communicative and taskbased language teaching as such it presented new challenges for teachers most of whom were either at the knowledge or persuasion stages at the start of their overseas professional development the course at the british university offered opportunities for participants to think about how to meet these challenges and make the shift to the decision stage there was clear and consistent evidence irrespective of the period which had elapsed since the time spent overseas that all participants were now involved in implementation two recurrent themes emerged from interviews and focus group discussions differences in perceptions of the nature of learning which framed teachers approach to teaching and the deployment of specific practices associated with good practice in education or modern approaches to ele in relation to the first theme teachers offered many examples of transition from authority figure to supporter guide and motivator according to wang ling for instance before i went on the course basically there had been more theoretical stuff and teachers tended to dominate upon return students did more and we teachers became a guide there was also evidence of the ways in which teachers were making students the centre of curriculum design and classroom teaching dai han for instance described her approach to mixed ability teaching in terms of respecting students as individuals as every student is different their intelligence their study habits and their methods of study are all different this approach would appear to be in marked contrast with their practice in china before attending the course in the uk reflecting on what he would have done prior to the course fan daoming commented before i would probably ignore … those who really did not want to learn after i returned i felt there might actually be other reasons why these students did not want to study li mei described her amazement at her students imagination and creativity commenting that if students are simply asked to repeat things in order to remember them they are likely to forget if however they are encouraged to learn through doing their gains will be more real and sustained in a similar vein wang ling commented i used to spend too much time teaching grammar and imparting knowledge to the students now i try to make the learning of english more practical so that its a tool i ask students to practise using english more before the students had fewer opportunities to practise using english other evidence of the shift from knowledge transmission to a more constructivist approach concerned aspects of classroom organization and lesson planning frequent reference was made for instance to forms of cooperative learning teachers reported that group and pair discussions had not only promoted cooperative learning but also improved students ability to work and think independently interestingly participants such as wei wen reported that this approach was effective not only with younger students but also with the more examination oriented senior classes for example a specific aspect of grammar during revision i can ask the students to form groups to discuss this first if students do not understand any aspect of the grammar they can learn from the stronger students who can offer help to them after the students have a better understanding by learning from each other the teacher can then follow up these changes in teachers philosophy of and attitudes towards teaching and learning represented deeper level changes as a result of the opportunity provided for reculturing or deeper questioning and sustained learning by the programme at the british university such changes were likely to underpin and sustain innovation and change in teachers classroom practices in respect of the second theme changes in teachers pedagogical practices we saw evidence of practical techniques skills and strategies introduced on the course now being used in their classrooms they included for example gapped dictation mind maps story and song as well as different approaches to lesson planning and classroom organization gapped dictation offers a useful way not only of teaching listening comprehension but of promoting both the conscious learning and the subconscious acquisition of grammatical structures in a second language zang kezuo also highlighted the usefulness of this new approach to dictation for mixed ability settings for the teaching of listening i can design different tasks with the same material for three different levels a b and c according to students levels of language for the lowest level i only take out some prepositions for next level i only take out some verbs whereas for the highest level i will probably take out both prepositions and verbs… when i use it in my teaching it both saves time and caters for mixed abilities many participants mentioned the use of mind maps to help students learn vocabulary more effectively similarly they reported that the use of correction codes as a feedback technique not only helped to engage students and improve their efficiency of learning but also reduced teacher workload soaring a strategy used for the adaptation and integration of teaching materials there was similar enthusiasm for the possibilities opened up by project work inspired in particular by placements in uk secondary schools many of the participants had been encouraging their students to enhance their english language learning through independent investigation i was teaching a unit called new media i asked my students to make a blackboard poster based on their own interests they needed to collect their own materials and the students did really well when i came back i mobilised all the grades year groups to participate in projects… on the school open day we displayed a lot of the project work in english by the students although they might appear a bit basic and not terribly sophisticated there was a lot in it worth further exploration even our headteacher was impressed interviews focus group discussions and observation all pointed to the enthusiasm with which a wide range of new approaches were being implemented in schools though it would be premature on the basis of our data to come to any firm conclusions as to the degree of variation in practice between teachers reinvention in confirmation the last stage of the diffusion process individuals finalise their decision to continue using the innovation and it is often at this point that they use the innovation to its fullest potential unlike other theories of change the diffusion model focuses on the evolution of behaviours that better fit the needs of individuals and groups the success of an innovation depends on reinvention or how well it evolves to meet the needs of riskaverse colleagues observation interview and focus group data included examples of the reinvention of modern approaches in ele to the particularities of the chinese situation as hüttner mehlmauerlarcher reichl and schiftner point out in another context teachers are no longer considered to be merely applying theory to practice but rather as professionals constructing theory and theorizing their practice the present study revealed awareness of the need to adapt new approaches returnee teacher zhao liyan for instance described how she had localised ideas and techniques learned on the programme at the british university echoing the observations of writers such as hu wu yan and zheng and davison one of the main constraints in implementing change reported by the teachers was the examination system wan ling expressed frustration at her students weak speaking and listening skills which she considered to be a direct consequence of the need to spend time on examination preparation the head teachers and heads of english departments recognised this obstacle too one of the head teachers mr cai offered the following comments the only thing is some advanced pedagogical ideas cannot yet be fully implemented with the current educational situation in china … for some students if you differentiate some of the things she the returnee teacher cant really do feeling a bit constrained this is because of the constraints of the examination regime … our national examination system the actual needs of the parents and students and the utilitarian value attached to student progression and gaokao the university entrance examination these things have to be considered nonetheless some participants had found ways of incorporating ideas from the course even with older students in examination classes as evidenced by the experience of fan daoming a teacher from a key school in zunyi probably people all think that senior three is really geared towards gaokao and with the amount of pressure it should be pretty difficult to do activities or things like that but i want to say today first author … has just observed my lesson i felt the lesson was quite dynamic for a senior three class i believe teaching at senior middle school even at senior three we should not abandon activities or some of them we could motivate our students through activities so that they want to learn and its not me making them learn our observation of the lesson for senior three taught by mr fan daoming attests to his claim by carefully staging his lesson eg beginning with an english song as a warmer followed by several pair and group work activities yet with a focus on preparing students for the university entrance examination and ending with another english song he seemed to be able to make an otherwise boring review lesson more interesting and engaging although this practice was not totally new to him he commented in the interview that training in the uk had not only given him more confidence in the continued use of the technique but also inspired him to explore new ways there was evidence across the lessons of returnees that we observed of genuine effort to use or adapt activities from the course at the british university to encourage student communication and interaction the role of peertopeer conversations the question remains as to whether these innovations are limited to the teachers who participated in the programme or whether they are being integrated in the practice of their colleagues as hu points out there is no reason to assume that policy imperatives feed through to classrooms in a neat linear predictable and deterministic manner there was a certain level of expectation on the part of the csc the local education authorities and individual schools that returnees would cascade their learning to colleagues whenever and wherever possible the effectiveness of this approach to training depends of course on the levels of understanding achieved by those responsible and their ability to cascade their learning this model of professional development is therefore by no means unproblematic the responses of teachers who had not taken part in the uk programme suggested that they were at the second and third stages in the decision innovation process many of those who took part in focus group discussions spontaneously commented on their frustration with the routine nature of their own teaching as prabhu argues the enemy of good teaching is not a bad method but overroutinisation they were clearly impressed by the confidence demonstrated by their returning colleagues their dynamic approaches to teaching and the rich repertoire of new pedagogical ideas or tricks they could draw on from their overseas experience ms yang who took part in a nonparticipant focus group commented i can feel it their lessons are more alive they have experienced the authentic language and culture just like travel if you only rely on a tour brochure of a town or city you can probably only learn a small part of it but if you really want to learn its history and how it develops you probably need to go there and see for yourself what it is like you can learn more by getting into some depth … in our textbook students need to learn about british culture when we talk about britain … those who have been to the uk do not even have to look at the textbook they can directly relate to their own experience in the uk … i can feel the big difference the returnees were clearly opinion leaders the decision to adopt new approaches inevitably entails a level of risk it thus seems reasonable to speculate that the enthusiasm of respected teachers may offer reassurance to more riskaverse colleagues there was certainly no shortage of evidence of a strong desire on the part of those who had not participated in the uk programme to have a similar opportunity to be exposed to new ways of thinking a lesson that we observed delivered by ms liu an apparently capable young teacher was characterised by knowledge transmission and deductive presentation of language knowledge with a notable absence of interactive activities this approach to teaching was confirmed by her head of department who sat in on the lesson as very typical of ms liu during the follow up focus group ms liu commented on her own lesson and methodology and expressed the desire to be exposed to new ideas particularly those relating to classroom activities in order to encourage student interaction and introduce variety to her lessons it is difficult to assess from our data the extent to which the nonparticipant teachers whose lessons we observed and who contributed to the focus group discussions were representative of other english teacher colleagues there was every reason to suppose however that such teachers formed part of an early majority of teachers receptive to change the same openness to change reported in wangs survey of teacher responses to the new curricula and gus and yans study of british council teacher training partnerships with chinese universities was also evident in the responses of nonparticipant teachers in the present study since the main focus of our study was on returnee teachers far less data was collected from nonparticipants and the findings in relation to this group thus need to be interpreted with caution nonetheless in attempting to assess the impact of the uk training on classroom practice in china we find ourselves in agreement with robinson who observes t he adoption of new products or behaviours involves the management of risk and uncertainty its usually only people we personally know and trust and who we know have successfully adopted the innovation themselves who can give us credible reassurances that our attempts to change wont result in embarrassment humiliation financial loss or wasted time iv discussion while policy directives are unlikely to feed through to classrooms in a neat linear and deterministic manner this study offers ample evidence of the ways in which recent innovations in language teaching methodology are being used productively in schools in china for instance teachers who previously felt comfortable following a textbook now have access to more innovative ways of teaching similarly a sounder understanding of issues in language teaching and learning has increased their confidence thus a teacher who had already been using songs before attending the course now had a better understanding of the ways in which this activity could be used to motivate students findings of this kind are of particular significance given our focus on the western provinces where educational reform has tended to lag well behind developments in the large cities and coastal regions of the five qualities that determine success three aspects of the chinese situation predispose teachers to change two aspects constrain innovation looking first at the facilitating factors the evident dissatisfaction of many educators with the effectiveness of english teaching in china and the supportive policy environment can be assumed to positively predispose teachers to new teaching approaches two other qualitiestrialability and observable results also bode well for innovation new approaches to teaching permit different levels of experimentation on the part of teachers and therefore entail less risk chinese teachers form strong communities of practice creating opportunities to see the results of innovation and stimulate discussion of new ideas with colleagues they are organised into teaching research groups composed either of all the teachers of a given subject or a subgroup of the teachers of a subject for a given year group members of a teaching research group do their marking discuss their teaching and their students and undertake collective curriculum and lesson planning in a shared workspace or room as reflective practitioners they present endof semester reports on aspects of their teaching at group meetings they are also regularly involved in observing colleagues lessons in addition to these routine teaching and research activities senior teachers often mentor their colleagues when there are english teaching competitions at both local and national levels to showcase pedagogical skills and promote cpd an interesting phenomenon which to our knowledge is rarely seen in other countries other factors notably compatibility and ease of use militate against change the social constructivist underpinnings of the new approaches to teaching are seriously at odds with traditional values similarly simplicity and ease of use are likely to militate against change since the innovations in question require teachers to develop new skills and understandings in a complex situation of this kind the diffusion model would not predict the wholesale enthusiastic adoption of new methods and this is indeed the case sufficient conditions are in place however to challenge assumptions that the new approaches cannot be adapted for use in the chinese context in fact innovative approaches such as clt and tblt have been largely reinterpreted and adapted to fit the local sociocultural realities both in china and the wider asiapacific region the diffusion of innovations model has wide applicability and has been used in many contexts including agriculture and medicine other theories which focus more specifically on the management of change in education however also offer support for the notion that new approaches to language teaching have a place in chinese classrooms robinson and latchem for instance identify two conditions which need to be fulfilled if new teaching methods are to become established first they have to be proven in practice second they should be adopted by a critical mass of teachers who together reinforce each others beliefs reduce the risks of innovation and eventually change the culture of teaching central to this process are shared goals a supportive head teacher and a collaborative atmosphere in this respect the critical mass created by the british based programme in the western region over nearly a decade is significant it is an important resource on which the returnee teachers can draw as communities of practice in their efforts to implement innovation and change this is something missing in shorter or oneoff programmes additionally the organization of chinese schools can clearly be seen to offer structural support not only for conformity but also for change it is important to note that in china the space necessary for innovation is provided both by topdown policy and by bottomup buyin at the level of the school such buyin is facilitated by the strong communities of practice associated with teaching organised around research groups that encourage reflective practice with ample opportunities to observe and be observed and an emphasis on mentorship by more experienced colleagues the present study also has implications for the debate about cultural appropriateness of innovation and in particular communicative and taskbased approaches to language teaching in the context of such discussions it is clearly important to avoid the dangers of essentialism clt and tblt are not monolithic methods but ones which have undergone considerable modification over the years in many different parts of the world it is very rare that any teacher would religiously follow a strong form of these approaches there is now a greater appreciation that there is no single universal method for language teaching and a willingness to incorporate elements associated with other methods as an enlightened teacher or by encouraging teachers to engage with their sense of plausibility or pedagogic intuition the fact that the early history of clt was associated with assumptions of cultural superiority and universal application does not imply that there is nothing of value or relevance to chinese language classrooms and while chinese teachers are indeed influenced by traditional values this does not mean that they are either unable or unwilling of adopt ideas from other cultures provided adequate training and support are provided an important finding from the present study concerns the reinvention of the new approaches to better fit the chinese situation in this respect we find ourselves in agreement with researchers who stress the importance of building on rather than ignoring teachers cultural heritage and of promoting ownership of innovation harmer neatly summarises this position when he notes that every teacher is a product of their culture their training and their experiences and this is something to be celebrated not sanctioned he further adds that the problem is not methodology per se but how this methodology is adapted to fit the needs of students these observations clearly apply to participants in our study to assume that chinese culture is static with no room for teachers and students to manoevre would be a serious disservice to all concerned while traditional practices still seem to predominate there is evidence of willingness to experiment and change returnees have identified a range of practices and strategies which they have been able to adapt to their own local circumstances new approaches introduced as part of their overseas professional development have not however been adopted uncritically on the contrary teachers have been mindful of the constraints within which they work not least an examination system which has failed to keep pace with curriculum development it is important to acknowledge that the issues raised in relation to new approaches to language teaching in our study are not limited to china various writers have highlighted the need to culturally embed or mediate new teaching practices ellis for instance proposes that wherever possible teachers should find points of congruence between seemingly contradictory cultural norms and draws attention to the support for studentcentred teaching offered by the chinese proverb if you give a man a fish you can feed him for one day but if you teach him how to fish you can feed him for a lifetime in a similar vein tan cautions that communicative activities need to be tailored to suit the cultural needs of students in singapore suggestions include starting with traditional teachercentered activities such as questionandanswer exercises to elicit short responses from the children before moving on to more studentcentred activities such as roleplay and problem solving or asking children to copy a short list of words which they are going to use later as a bridge to more interactive activities based on these words finally we need to consider the trustworthiness of our data we were of course mindful of the potential positive image that participants might want to project of their experience however it is important to remember that demonstration classes are a wellestablished feature of professional life in china it could be argued therefore that chinese teachers are less likely to modify their behavior when observed than teachers in other settings there was certainly no compelling evidence that the lessons we observed were more artificial than their normal practice on the contrary interview data suggested that the techniques and activities observed had already been integrated into the teachers normal practice in addition both interview and observation data pointed to variation in the rates at which innovations had been adopted as indeed the diffusion model predicts v conclusion our focus in this paper has been on the extent to which new approaches to language teaching are being applied in the classroom and on the ways in which these approaches are being adapted to meet local needs by applying tenets of the diffusion model and in particular the stages of the adoption process the characteristics of innovations that influence the success of an innovation and the notions of opinion leader and reinvention we have been able to account for many aspects on the current situation in the western provinces of china evidence that returning teachers were implementing innovations introduced as part of their overseasbased professional training included a shift from authority figure to supporter guide and motivator similarly there were extensive examples of the ways in which teachers were making students the centre of curriculum design and classroom planning using a variety of practical teaching techniques and strategies support from central government policy and senior management enhanced the trialability of their efforts and the ease with which they were able to experiment with new methods in the classroom teachers varied to some extent however in their confirmation of the innovation with relatively few for instance reporting ways of integrating communicative and taskbased approaches in the senior examination classes there was also evidence of the reinvention which marks successful innovation in the form of new approaches localised in response to poor levels of resourcing large classes limited teacher proficiency in english and an examination system which is often a poor fit with the expectations of the new english curricula a new wave of curricular reform in china however as exemplified in the recently published english curriculum standards for compulsory education to be implemented nationwide from september 2012 is set to change the situation and will offer further policy support for the kind of innovation discussed in the present article there was also evidence that these innovations were being cascaded to their colleagues while recognizing that the principles underlying the new approaches to language teaching may be at odds with principles underpinning traditional classrooms various aspects of the course programme in the uk and situation in china are supportive of innovation in the context of the rise of english as a global language dissatisfaction with the educational outcomes associated with textbased learning has been a catalyst for greater openness towards alternative approaches as embodied at the policy level in the new curricula the organization of teaching in china around research groups and the emphasis on reflective practice are particularly supportive of diffusion as are the demonstration classes and local and national competitions all point to the observability of the innovation the decision as to whether to adopt or reject change involves the management of risk and uncertainty the overseas trained teachers are opinion leaders with considerable influence among their peers the fact that trusted colleagues have successfully adopted the new methods therefore offers valuable reassurance although there is always the risk of resistance to topdown policy reform there was clear evidence of early majority participation in change we are mindful however that a more accurate assessment of the extent of diffusion would have required a much larger sample of nonparticipants and a longer period of fieldwork

this paper assesses the impact of a ukbased professional development programme on curriculum innovation and change in english language education ele in western china based on interviews focus group discussions and observation of a total of 48 english teachers who had participated in an overseas professional development programme influenced by modern approaches to education and ele and 9 of their colleagues who had not taken part it assesses the uptake of new approaches on teachers return to china interviews with 10 senior managers provided supplementary data using diffusion of innovations theory as the conceptual framework we examine those aspects of the chinese situation which are supportive of change and those which constrain innovation we offer evidence of innovation in classroom practice on the part of returnees and reinvention of the innovation to ensure a better fit with local needs the key role of course participants as opinion leaders in the diffusion of new ideas is also explored we conclude that that selective uptake of this innovation is under way and likely to be sustained against a background of continued curriculum reform in china

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introduction brazils public health system o sistema único de saúde or unified health system has gone through profound changes since the first case of covid19 was confirmed in the country in february 2020 the devastating pandemic that ensued imprinted important changes in work processes across different services which were forced to adapt protocols operational flows and other care arrangements in response to the preventive measures implemented to curb the spread of sarscov2 in addition the public health emergency increased the burden and pressure on health workers initially resource allocation prioritized severe cases and increasing the availability of hospital beds with primary health care being reduced to secondary status despite its capillarity across brazils municipalities and capacity to implement pandemic control measures health surveillance health care support for vulnerable groups and routine service interventions are some of the activities that should be developed in this scenario 1 2 3 with the start of mass vaccination phc was brought back to the forefront due to the expertise and experience of the primary care workforce in the implementation of vaccination campaigns in the midst of poor national coordination and a weak federal government and ministry of health response to the ensuing pandemic the disease spread out of control this lack of control was reflected in the large number of cases and deaths and duration of the pandemic 4 there were also delays in the implementation of measures to support the economy and employment leading to the resurgence of social vulnerabilities 5 with the spread of the pandemic and increasing number of cases of covid19 other demands arose including treatment of long covid 6 the various direct and indirect longterm effects of the pandemic such as mental health problems deepening poverty and food insecurity as well as the aggravation of chronic conditions caused by the temporary disruption of followup treatment increased strains on health services and led to the mobilization of different levels of care especially phc 278 expanded family health centers made up of interprofessional teams 9 that provide specialist rearguard support in phc focusing on collective and group interventions also needed to adapt to the pandemic under a matrix support organizational framework nasf specialists provide primary care centers with technicalpedagogical and clinicalcare support 10 how supporters and supported teams work engenders different support function arrangements and configurations which in turn affects health care delivery a nasf can be understood as a team that enhances shared expanded care through matrix support matrix support is a shared management resource that promotes more dialogical and less vertical work processes 11 to be effective it requires certain institutional arrangements such as team meetings and other protected collective spaces that should be valued and legitimized by management however due to covid19 these arrangements have been reduced or temporarily suspended nasf specialists have an essential role to play in the response to the covid19 pandemic and other public health emergencies 12 which in turn implies the need to generate knowledge about new modes of working despite the attention given to matrix support by the literature little is known about the work of nasf teams in times of pandemic the aim of this study was therefore to analyze new configurations drawing on the data from a qualitative study investigating nasf work processes in maricá rio de janeiro brazil methods the study was conducted in the second semester of 2021 in maricá which is part of the state of rio de janeiros metropolitan region ii and had a population of 168000 in 2021 according to the brazilian institute of geography and statistics undergoing an expansion process phc coverage was around 98 of the projected population with 54 family health teams working in 24 pccs and 6 nasf teams with 48 staff it is worth mentioning that unlike national trends during the study period 12 the number of nasf teams in the municipality increased from 2 to 6 we adopted a qualitative approach as according to minayo 13 qualitative methods allow the researcher to understand peoples interpretations of how they live construct artifacts and themselves feel and think furthermore work processes go beyond the regulations that shape professional practices being played out in encounters between concrete subjects who have beliefs desires values and interests the restrictions imposed to curb the spread of covid19 were considered when defining the methods for this reason we used a combination of primary and secondary data obtained from a web survey semistructured interviews document analysis and sus information systems the data were gathered and processed separately and integrated and combined in the discussion 14 online surveys are practical and do not require facetoface interaction using focus groups or facetoface interviews would have increased the complexity of the research process given the restrictions that were in place and the unpredictable epidemiological scenario at the time of data collection a web survey was therefore conducted to map and understand modes of organization of the nasf work processes during the pandemic the survey was created using google forms and consisted of 1 openended question and 25 multiple choice questions none of which were obligatory we avoided questions that could identify the respondent due to the researchers involvement in the area in many of the questions it was possible to choose more than one option while others used a likert scale given that matrix support has multiple modes of functioning and possibilities of professionalprofessional interaction 1516 after tabulating the survey results we performed a preliminary analysis of the data to identify relevant points that could serve as a frame of reference for the individual interview guide to gather complementary information that the web survey did not capture due to the limitations of this method 17 we interviewed three former managers and technical supporters of the social health organization that took over the management of the municipalitys primary care services in march 2020 two of the interviews were online and the third was conducted facetoface at the request of the interviewee taking the recommended precautions two other data collection techniques were also used document analysis to identify and discuss the development of nasf guidelines and regulations between 2008 and 2021 and the analysis of secondary data taken from the suss primary care health record system esus and the national registry of health facilities to crosscheck data on the expansion of fhs coverage in the municipality and number of nasf teams and staff data analysis was performed using the hermeneuticdialectic method the primary data comprised the results of the interviews which are products of a singular experience mediated by collective experience in this sense the data is circumscribed by concepts and modes of working that either converge towards or deviate from the rules and regulations as the latter are reframed by the actions of the agents who enact them and these agents simultaneously hold collective interests which bring them together and individual interests which distinguish them from each other and counterpose each other 13 we developed a conceptual framework illustrating the relationship between the concept of matrix support and the work activities listed in the primary care guidelines and specific roles and responsibilities described in the 2017 national primary health care policy 1819 these documents were chosen because cab no 39 is the main guidance document for everyday work practices in nasfs and the pnab was the prevailing relevant policy at the time despite changes implemented in recent years 2021 the conceptual framework was not intended to limit the scope of the study or prevent different types of modes of operation of matrix support from appearing rather it was used as a tool to assess compliance with a set of recommended practices and compare that which is on paper with actual practice using the framework as a frame reference to create singular maps 22 that reveal practices that go beyond that which is prescribed to synthesize and facilitate understanding of the phenomenon under study 13 we used 5 categories of analysis professional profile of the nasf members what is valued by the management interprofessional relations modes of comanagement 11 adopted by supporters and supported teams work processes during the covid19 pandemic forms of organization of professional practices during the pandemic health patterns during the pandemic health problems identified during the period and management and the nasf support provided by city council technical areas and the oss for interventions performed by the specialists these categories intersect with the conceptual framework helping to gain a deeper understanding of the limitations of the prevailing rules and regulations in face of the health needs arising from the pandemic there is an open agenda when it comes to nasf work processes with the latter being shaped by new demands and specialist duties roles and responsibilities not envisaged in cab no 39 and the pnab these shortcomings result in the need to develop new guidance and official rules and regulations addressing the specific needs of the pandemic the study was conducted in accordance with ethical and legal norms and standards for research and the study protocol was approved by the research ethics committee after approval we initiated warmup in the field a strategy used to maximize adherence to the study initially we presented the study at the meetings of the 6 nasf teams to explain the objectives and methods and emphasize the importance of conducting an indepth analysis of work processes each meeting was attended by an average of 5 professionals and held in a wellaired open space using personal protective equipment before sending the web survey by whatsapp we sent a text to the team whatsapp groups reiterating the explanation given at the meetings confirming that participation in the study was voluntary and that any information provided would remain confidential the web survey link was sent individually to 38 professionals selected according to the inclusion criteria working in the nasf team for at least 3 months two reminders were sent over a period of 28 days one after 8 days and the second during the last week of the period this strategy was adapted from previous studies using mail surveys where reminder letters were sent 23 in this case replaced by text messages thirtytwo professionals answered the survey corresponding to 84 of the individuals contacted results and discussion at the time of data collection there were 6 nasf teams with 48 members 7 physiotherapists 6 social workers 6 nutritionists 6 psychologists 5 pharmacists 5 speech therapists 5 pediatricians 4 physical educators 3 obstetriciangynecologists and 1 nurse each nasf team provides support for between 8 and 10 family health teams amounting to a total of around 54 teams 1 street clinic and 1 indigenous health clinic covering 100 of the municipalitys primary care teams there were 2 types of employment contracts and 4 working hours arrangements differences in working hours directly affect support capacity resulting in overburdening for some professions doctors for example need to divide the 16 hours to be able to provide support for up to 10 teams this also occurs with some physical educators who provided support for all the teams in the health district they are allocated to in addition this type of arrangement significantly decreases the presence of specialists in minimum teams sometimes hampering participation in team meetings case discussions home visits and comanagement between the nasf team and family health team resulting in a more vertical approach configurations of support in maricá chart 1 shows the results of the work processes mapping done using the primary data broken down into the 5 categories of analysis these data reveal types of arrangements modifications and the interventions performed by the specialists after the changes driven by the pandemic the results show that a little over half of the professionals joined the nasf during the pandemic constituting new teams however most of the staff had experience with matrix support in other municipalities before joining this is possible when policies and practices are consolidated through an increase in the number of qualified staff resulting from investment made by the ministry of health from 2008 interrupted by the programa previne brasil 1221 most of the team members sought out pandemic training opportunities however a considerable proportion did not attend covid19 training despite major changes in organization and interventions some professionals participated in training offered by organizations outside the sus although it was not possible to guarantee the quality and depth of these courses it is important to highlight that a number of professionals received training from the supported teams revealing that support was twoway another important point is that little investment was made by the city council technical areas and oss to promote the discussion of covid19 with only 125 of specialists mentioning that they participated in training offered by local management the lack of training offered by local management reveals a low level of investment in continuous training and professional development the training of nasf professionals gains even greater relevance as acquired knowledge reverberates in the supported teams either through knowledge and practice sharing or direct patient and group care however respondents reported that local management provided key support to specialists concerning covid19 issues behind only nasf members themselves who provided the highest level of support during the pandemic nasf work schedules were defined together with the supported teams and other specialist professional profile of nasf members new team with most members joining during the pandemic due to a switch in management of phc half of the team members had worked in matrix support before joining the team most team members received training in matrix support from local management particularly those who had joined the team before the pandemic a little over half recognized that the official government documents that guide matrix support practices contribute to their work processes interprofessional relations nasf work schedules were defined jointly with the supported team however some specialists defined schedules independently the professionals who most sought nasf support were nurses and chws most of the cases referred to specialists were discussed upon referral or during followup specialists participated in family health team technical meetings at the invite of mangers and upon the initiative of the nasf which offered to be present in group meetings interconsultations involved mainly nasf members and family health team nurses nasf specialists worked jointly with other nasf members in many actions nasf teams held periodic internal planning meetings with the participation of most of the team support materials and continuous training was offered to supported teams when the need was identified or when requested by teams or patients work processes during the covid19 pandemic most team members took part in pandemic training activities however a considerable number of professionals reported not having participated in training on covid19 new work processes were discussed mainly with nasf members from the health district with guidance being provided by management nasf professionals reported that the professionals who provided most support during the pandemic were other nasf members most specialists mentioned that there was an increase in demands over the course of the pandemic individual appointments were held respecting all protocols collective activities were suspended temporarily being resumed with the adoption of health protocols home visits were performed with a reduced number of professionals the services provided by the psychosocial care network were the most requested by nasf teams whatsapp was the most widely used communication tool to provide remote support to patients and supported teams using text messages and voicemail many professionals reported not providing remote support to patients physical structure was considered inadequate for the work of professionals during the pandemic health patterns during the pandemic the most mentioned problems were mental health problems especially anxiety followed by problems in the category diet and nutrition besides psychosocial care network services nasf teams also requested social assistance services during the period nasf management the professionals reported that management was supportive when it came to issues involving covid19 few training opportunities were offered by the city council to discuss aspects related to the pandemic the way in which information on the health care network was made available was considered satisfactory general meetings promoted by local management were considered spaces that provided the opportunity for discussion team members planning interventions together with those who request support and collectively discussing how they will be performed means that those who contract the interventions share responsibility for actions when the latter are involved in the planning and management of work processes health care gains a different meaning for those who deliver it with gains that extend beyond utilitarian value work producing a commodity health care and engendering changes in the worker 11 another relevant aspect of this arrangement relates to intervention enabling conditions such as physical infrastructure and protected physical spaces for group activities interconsultation and individual appointments home visits for example depend on certain conditions such as guaranteeing transport to the patients home this requires joint planning to establish agreements between teams with support from local management the results show that the professionals who most seek support from nasf teams in this context are nurses and community health workers followed by doctors pcc managers auxiliary nurses and dentists andor oral health teams one of the managers suggested that this may be explained by various factors including the fact that the number of chws per team is higher than other professionals and these workers continued to work in local communities even during the pandemic another reason is that chws are authorized by the technical area to directly request nasf support decentralizing procedures and ensuring that support is not restricted to doctors and other professionals with degreelevel qualifications the results of one of the likert survey questions show that the main partners of interconsultations were nasf professionals followed by nurses and doctorsnone of the 32 specialists who responded the survey selected the maximum score from a scale of 1 to 5 for joint appointments with doctors in contrast to other professionals who obtained at least one maximum score this may have a number of explanations first it may not have been possible to offer interconsultations due to the social distancing measures introduced to curb the spread of covid19 second it could due to lack of openness of doctors to specialists or viceversa another factor that hinders interconsultations is conflicting work schedules on the days nasf professionals are in the pcc and availability of doctors for shared consultations according to the interviewees when specialists come up against barriers to accessing family health teams and are unable to link up with minimum teams they often seek space together with fellow team members with regard to interconsultation besides knowledge sharing it is important that the professionals who are sharing the case hold joint responsibility these consultations should not be restricted to the family health team receiving a second opinion or technical advice from a specialist 24 in shared consultations groups of different professionals interact with the patient and with each other in an action involving different forms of management of the health problem the technicalpedagogical dimension of matrix support operates through collaboration and observation with knowledge and practice sharing enhancing the capacity of all involved to deliver effective care one of the main challenges of matrix support is to develop a working model in which actions and interventions are comanaged to this end teams need to have spaces for discussion and joint planning while case discussions alone do not guarantee comanagement without this practice the old forms of referral that the nasf aims to overcome are repeated 18 more than that both teams need to believe in the power of teamwork realize the importance and greater effectiveness of this type of arrangement and be open to cooperating and task sharing in collective spaces group patient activities were temporarily disrupted due to the implementation of social distancing measures to curb the spread of covid19 on the other hand there was an increase in individual appointments usually in the form of interconsultations elective appointments and certain lines of care had to be suspended affecting nasf performance indicators according to one interviewee there was also a reduction in the number of professionals doing home visits and less activities were developed in the community due to the temporary disruption of group activities work processes were organized in a more individualized manner inside clinics this modus operandi is different from that usually adopted in primary care 23 which combines individual care with a communitybased and familycentered approach many specialists reported that they did not use telesupport or teleconsultation even when social distancing measures were in place in this respect it is worth highlighting that the nasf did not have an institutional telephone at the time of data collection by not having access to a protected number many workers may not have felt comfortable giving their personal telephone number and mixing professional and personal life receiving calls and text messages outside working hours and meeting demands that go beyond the requirements of their role an important consideration is the feasibility of telesupport given that many patients have low socioeconomic status and may not be able to afford a smartphone and internet or are older persons who do not have the necessary knowledge and experience to use communications technologies care should therefore be taken to ensure that greater use of these tools does not become a new barrier to access producing health inequities according to fonseca and morosini 25 different aspects should be considered when expanding the use of digital communication technologies including the loss of importance of territorialization due to the reduced circulation and presence of health professionals in the local community the authors also highlight the need to be attentive to the risk of exacerbating the invisibility of the social dynamics of disease and limiting the focus of care emphasizing clinical aspects that reinforce the complainttreatment approach that the fhs seeks to overcome 25 on the other hand most professionals provide remote support to supported teams especially using whatsapp this communication tool is widely used by health professionals and many cases were already being shared using this platform even before the pandemic however exchanging messages alone does not constitute comanagement of care with the platform often being used to pass information through superficial communications giving a false sense of sharing and working as a team 26 health problems related to the covid19 pandemic the results of the question about types of demands related to the pandemic the only openended question in the web survey revealed 37 problems which are listed in chart 2 according to strategic nasf areas 27 the last column shows the number of times each problem was mentioned however this division is merely schematic given the multifactorial nature of most of the problems the most cited problems were mental health problems which is consistent with national data a recent study showed an increase in the number of workers insured by national social security institute on longterm sick leave due to mental and behavioral disorders in 2020 revealing that the pandemic has had a major impact on mental health in brazil 28 as a reflection of this situation there has been an increase in the utilization of the services of the facilities that make up the local psychosocial care network including 1 psychosocial care center ii 1 child and youth psychosocial care center 1 psychosocial care center for alcohol and other drugs and 4 multidisciplinary psychosocial care teams run by the city council to replace the outpatient model the second most common problems were those related to diet and nutrition the most mentioned problem was obesity followed by weight gain overweight poor eating habits and eating disorders hunger was also included in this category although this problem may also be encompassed by the social service category as it is related to increase in poverty lack of family income and unemployment although intrafamily violence was also included in this category it is understood that violence is multifactorial the most common problems in the category rehabilitation understood here in the widest sense of the word were motor sequelae generalized pain and joint pain which may be associated with problems related to a sedentary lifestyle lack of physical activity and muscle weakness included in the body practices and physical activity category although limited in number the problems included in this category provide some insights into health needs after the advent of the covid19 pandemic 6 the multifactorial and multicausal nature of most of the problems listed in chart 2 reinforces the importance of the comanagement of health interventions by interdisciplinary teams given the persistence of symptoms associated with the disease associated problems and long covid it is essential to develop guidance documents like those published by the ministry of health during the zika public health emergency in 2016 29 it is worth highlighting that the lack of technical guidelines and organizational and clinical regulations for nasfs during the pandemic resulted in the emergence of selfmanaged processes in teams who had to create or customize singular forms of working the following is a list of nasf interventions identified in the investigated work processes and literature review telesupport for supported teams teleconsultation and telepatient monitoring replacement of group appointments with remote activities and groups production and dissemination of informative material on the pandemic and videos showing remote health actions psychosocial support for supported teams and patients support for testing and vaccination strategies identification and follow up of patients with long covid19 symptoms monitoring of socially vulnerable groups and identification and mobilization of support networks in health territories 238 30 31 32 33 the list of activities reveals the modes of organization of matrix support throughout the pandemic with the possibility of incorporating many activities into nasf practices in other contexts other practices were already used by the specialists and expanded during the pandemic such as information and communication technologies which began to be used en masse especially for team communication as mentioned above care must be taken to ensure that the utilization of digital communication technologies does not pose a new barrier to access to services or result in a detachment from family health team roles and responsibilities in this sense it is important to be attentive to the possible distancing of health professionals from the community ensure that the replacement of facetoface contact by remote interaction does not result in a loss of longitudinality and reduced engagement with patients and families and assess whether the reduction in facetoface group interaction implies weakening community engagement and the collective 2526 it is important to highlight the importance of identifying patients with symptoms of long covid19 and the proper followup and monitoring of cases that can be managed by primary care services using collective and individual care strategies this reinforces the need for family health teams to pay more careful attention to patient needs and the importance of interprofessional support for emerging cases regardless of severity 238 it is also important to understand the technical limitations of these teams in unpredictable scenarios such as those experienced during the pandemic final considerations this study revealed that new modes of organization of matrix support work processes became more prominent during the health emergency confirming the study hypothesis at certain times the teams needed to shift away from the communitybased approach temporarily disrupting groups and home visits focusing on individual care interventions during severe periods and performing functions apparently out side the scope of their core duties and the roles and responsibilities of phc these possible and necessary configurations were determined by the circumstances of the pandemic playing a pivotal role in the organization of the work of health teams matrix support needs to constantly adapt to the conjunctural needs of the sus driving instituting movements and processes of creation in the case studied here the pandemic forced a rethink and the modification of work practices in health services the advent of the pandemic expanded the list of clinical demands addressed by phc which require further clarification these demands justify the existence of nasf teams and matrix support which operate by developing actions with supported teams and delivering care directly to patients and groups the multifactorial nature of most problems arising during the pandemic identified by this study reinforces the importance of the interprofessional approach adopted by the nasf monitoring health needs modifying modes of operating and interventions has to do with the permanence of the nasf in the sus and is a way of counterposing the dismantling of the public health system witnessed during the study period the resumption of funding of the nasf redesigned for a newly shaped team the emulti a multidisciplinary primary health care team 34 reaffirms the importance of matrix support for the provision of comprehensive longitudinal care through shared consultation and case discussions the joint definition of therapy plans and interventions in the community advances are also being made in the form of modifications and new practices such as the incorporation of remote care one of the legacies of the pandemic and the establishment of performance indicators from 2024 with regard to methodology analyzing the results of the questionnaire before the interviews with managers allowed us to identify relevant points for inclusion in the semistructured interview guide and gather complementary information that the web survey did not capture due to the limitations of this method in addition the infield warm up where we presented the study at team meetings and sending reminder whatsapp texts contributed to the adherence of workers to the study the analysis was limited to nasf professionals and managers with members of the supported teams and patients not being included demonstrating the importance of further research on this topic this was due to time constraints and the circumstances of the covid19 pandemic limiting the scope and breadth of the study collaborations boths authors were responsible for study conception data analysis and interpretation and drafting the article and approved the final version to be published repository scielo data

the aim of this study was to analyze the different configurations of matrix support stemming from changes prompted by the covid19 pandemic by investigating the work process of an expanded family health center nasf in maricá rio de janeiro brazil we conducted a qualitative study using data collection methods selected according to the circumstances of the pandemic web survey semistructured interviews document analysis and searches of health information systems the data were analyzed using the hermeneuticdialectic method the findings show an increase in mental health problems among both patients and health workers the need to mobilize sociopsychological support networks an expansion of remote support especially for professionals from supported teams and reduced presence of specialists in the community the study shows that work processes became more individualized and focused inside clinics and that minimum teams had limited capacity to care for the health problems related to covid19 confirming that nasfs play an essential role in primary health care

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background i n many subsaharan african countries service delivery modalities such as mobile outreach services and special family planning days play an important role in increasing the use of modern contraception especially underutilized longacting reversible contraceptives and permanent methods 1 2 3 4 5 6 7 mobile outreach services are crucial for increasing equitable access by design they serve poorer marginalized and geographically hardtoreach communities and populations 4 7 8 9 such services are characterized by the deployment of trained providers to lowerlevel health facilities or temporary setupssuch as tents or community spacesthat are equipped with the required contraceptives and supplies 67910 special family planning days are distinct events that are welladvertised in the community and organized at higherlevel facilities during which a full range of contraceptive methodsincluding larcs and often permanent methodsare available trained providers and counselors assemble in sufficient numbers to dedicate themselves to family planning for the day and plan to have sufficient stock on hand thereby creating confidence in the community and among clients that family planning methods will be available both of these nonstatic service delivery modalities increase access to family planning especially to larcs for women who may not have routine access to a wide contraceptive method mix or to family planning at all although shortacting methods such as hormonal injections and pills are highly popular with family planning adopters in subsaharan africa studies show that when women are able to choose among a wide range of contraceptive options significant proportions choose larcs 1591112 due in part to global investments since the 2012 london summit for family planning hormonal implants have become more available and as a result women are especially likely to select implants as compared with other contraceptive methods including intrauterine devices when they are available 58 13 14 15 16 although implants continue to represent a smaller proportion of the method mix in subsaharan africa they are one of the most rapidly growing contraceptive methods globally 12 engenderhealths expand family planning project funded by the bill melinda gates foundation aimed to increase contraceptive options with a focus on larcs for women and girls in the democratic republic of the congo tanzania and uganda the project began shortly after the 3 countries set aggressive goals at the london summit the government of drc committed to achieving a national contraceptive prevalence rate of 19 by 2020 ugandas government committed to reducing unmet need to 10 by 2022 and tanzania committed to doubling the number of family planning users to reach a national cpr of 60 by 2015 17 although tanzania did not achieve 60 cpr within their stated time frame the government recommitted to its family planning program adding financial resources and a pledge to increase the availability of youthfriendly health services 18 all 3 countries recommitted to their family planning goals at the london summit meeting in july 2017 adding pledges to protect respect and fulfill client rights to full free and informed contraceptive choice 19 as a result of publicand privatesector family planning initiatives supported by governments donors and technical assistance partners significant progress has been made in family planning use overall and in use of larcs more specifically for example in kinshasa drc rates of larc permanent method adoption increased quicklyfrom 25 prevalence in 2013 to 53 in 2015as these methods became more available 20 in uganda the 2016 demographic and health survey showed that the overall cpr was increasing with the prevalence of implant use among married women more than doubling in 5 yearsfrom 27 in 2011 to 63 in 2016and with iuds remaining a much smaller proportion of the method mix but still tripling from 05 to 15 2122 in tanzania the prevalence of implants nearly tripled among married women between the 2010 and 2015 dhsfrom 23 to 67 though iuds remained below 10 2324 in all 3 countries engenderhealths program introduced a voluntary human rightsbased approach and framework at national and project implementation levels the goal was to build provider awareness and capacity in voluntary family planning programming including counseling to ensure that clients were able to make full free and informed choices and that programs assured equity and quality in the provision of care 2526 full choice is defined as access to the widest range of methods possible to what degree that is possible may depend on what methods are approved for use at the national level and any constraints on the type of facility or cadre of provider free choice is a voluntary decision without barriers or coercion about whether to use family planning and if so which method to use informed choice is a decision based on complete accurate and unbiased information about family planning method options including benefits side effects risks and information about the correct use of the method chosen and the risks of family planning nonuse 27 the concepts of quality counseling and ffic are interrelated and fall within a larger framework of client rights the ffic framework includes many elements of nonstatic service delivery modalities such as mobile outreach and special family planning days increase access to family planning especially to larcs counseling quality such as information on the array of contraceptive options available to the client and the benefits and side effects of each option and how to discontinue use when the client wants or needs to have an iud or implant removed however ffic goes beyond counseling quality and other measurement frameworks by assessing a clients ability to obtain her method of choice and by asking her who is primarily responsible for deciding whether to use family planning and which method these specific elements of ffic are influenced by factors that are external to provider counseling such as method availability cost of methods and spousal influence to enhance ffic the expandfp project invested resources into focusing on family planning clinical and counseling training for providers facilitative supervision infrastructure and contraceptive security improvements community engagement and advocacy the project supported national trainers to train family planning providers on clinical contraceptive methods and rightsbased counseling techniques trainings were followed by onsite provider follow up and coaching facilitative supervision was conducted at least twice a year in higherlevel supported facilities where special family planning days occurred the interventions supported service delivery for both shortacting and longacting methods permanent methodsmale and female sterilizationwere not offered at study facilities in the drc but were available at most facilities in tanzania and uganda projectsupported publicsector special family planning days used community health workers mass media and dedicated family planning providers in addition the projectsupported publicsector mobile outreach teams of dedicated family planning providers to serve lowerlevel facilities in remote areas with shortacting longacting and sometimes permanent family planning methods for both special family planning days and mobile outreach community mobilizers were engaged to inform the community about upcoming events although special family planning days were conducted at facilities that generally had the most methods available they frequently struggled with stockouts and provider unavailability while mobile outreach events typically occurred in smaller facilities that usually only had shortacting methods in tanzania and uganda all family planning methods were provided free to clients at public facilities at all times in the drc family planning methods were only free to clients during special family planning days and at mobile outreach events special family planning days and mobile outreach events served higher client loads than routine services in all 3 countries and were particularly high in the drc and tanzania on average for special family planning days 97 clients were served per day in the drc 112 in tanzania and 33 in uganda on average during mobile outreach events an average of 60 clients were served per day in the drc 133 in tanzania and 23 in uganda during these events clients obtained information both from group educationcounseling sessions and from individual counseling with the provider with heightened awareness of ffic and data showing significant increases in the number of hormonal implant adopters especially in the drc government officials and program managers moved to increase their monitoring of ffic especially during highvolume mobile service delivery and special family planning day events steps to assess ffic included improving supervision of counseling and conducting this study of client perceptions of quality and choice 28 this study investigated and compared aspects of ffic and quality service delivery from the client perspective for routine static services mobile outreach and special family planning days our primary interest was to understand clients experiences of ffic and whether elements of ffic varied by service delivery mode in project catchment areas we also analyzed characteristics of the family planning clients to understand the populations reached by the 3 service delivery modalities in each country this article adds to the literature because previous studies have focused their research on ffic and client satisfaction in private versus public clinics 29 the quality of mobile outreach services 3 and how clientcentered counseling can improve client satisfaction 3031 while many tools exist to aid programs in humanrights based programming and monitoring they have seldom been brought to scale in national programs or measured systematically 32 this study goes beyond the current literature by comparing ffic and client satisfaction among 3 service delivery modalities and underscoring the value of using existing tools to provide valuable monitoring data to inform program needs methods we conducted a crosssectional facilitybased survey between april and july 2015 at 30 engenderhealth supportedfacilities 9 in the drc 13 in tanzania and 8 in uganda in tanzania and uganda the facilities selected were in periurban and rural areas whereas in the drc the facilities were in periurban and urban areas of kinshasa the study purposefully selected facilities geographically spread across districts receiving support from engenderhealth each data collection site had mobile static or in the drc only special family planning day services during the project period facilities were chosen for data collection by service delivery mode based on the timing of family planning service activities type of support from engenderhealth and expected client load some facilities had routine client loads too low to make reaching the desired sample feasible and thus were excluded facilities for mobile outreach collection were selected based on the scheduled mobile outreach activities during the data collection period trained data collectors conducted exit interviews with clients immediately following their family planning visits clients were systematically sampled using an interval based on expected client load and were interviewed privately using a structured questionnaire signed informed consent was obtained in local languages prior to the interview eligible respondents were women aged 15 to 49 years seeking family planning services during static family planning service delivery or mobile outreach services and who were not pregnant clients aged 15 to 17 years were eligible if they were legally emancipated all data collectors were women to reduce respondent discomfort with questions related to reproductive behaviors and intentions outcomes the main outcomes assessed were measures of ffic and client satisfaction outcome indicators are defined in detail in table 1 indicators 1 through 13 directly correspond to responses to questions from client exit interviews that asked clients to report on the elements of counseling they received and their personal choice in method adoption the majority of questions required a yesno response 1 recorded for a yes answer and 0 for no indicators 1 and 2 were assessed among all respondents indicators 3 through 9 among all respondents receiving a method and indicators 3 through 13 among women who received a larc the proportion of positive responses were tabulated within the denominator category specified in table 1 to examine counseling and choice elements as a whole not just individually composite ffic scores were constructed by summing the positive responses for indicators 3 through 9 for women receiving any method and summing positive responses from indicators 3 through 13 for women receiving a larc method ffic scores were examined in 2 ways as a proportion of women who reported affirmatively to all elements in that category of user and as a mean score of positive responses the highest score possible for women receiving any method was 7 and the highest score for a woman receiving a larc was 11 we assessed satisfaction using a 4point likert scale respondent was very dissatisfied somewhat dissatisfied somewhat satisfied or very satisfied recognizing that courtesy bias contributes to high levels of satisfaction and that reporting somewhat satisfied versus very satisfied may indicate a small amount of dissatisfaction we analyzed elements of satisfaction using a dichotomous variable categorized as very satisfied versus the rest client characteristics assessed were reproductive intentions parity marital status age education attained and literacy as well as 2 proxy measures of socioeconomic status mobile phone ownership and home electricity we also examined previous contraceptive use method preference and reproductive intentions as well as method received on the day of service answers from 13 indicators were used to arrive at a final composite ffic score to measure clients positive perceptions of and satisfaction with their service delivery experience table 1 indicators of full free and informed choice and rationale for inclusion indicator rationale denominator received an fp method clients receiving fp is key to ffic however a client not receiving a method does not necessarily demonstrate a lack of choice a client may come for removal other services or choose not to adopt a method all women 2 reported being asked about reproductive intentions providers knowledge of a clients desire to delay space or limit childbearing is important for recommending appropriate methods reported discussing 3 or more methods with provider clients should be aware that they have options to select the method best suited for them client given a chance to ask questions clients in any clinical setting should be given an opportunity to ask questions obtained fp method of choice full choice and free choice are contingent on the client receiving her desired method the reasons for not receiving the desired method include unavailability of the method lack of a trained provider cost medical contraindication or other women who adopted an fp method 6 participated in fp decision making clients should have agency in choosing their method either by themselves or together with the provider with a partner or with someone else if the client reported that someone else made the decision for her a lack of ffic is indicated counseled on method received the client being given general information on the method received is key to being informed counseled on benefits of method received the client being told the benefits of the method received is key to being informed counseled on side effects of method received the client being told and understanding the side effects of the method received is key to being informed and can also prevent early discontinuation 10 told where to get implantiud removed a client should know the effort required to have the larc removed before she adopts it women who adopted a larc 11 told when to get implantiud removed a client should know when to have the larc removed this is key to correct use and fulfilling reproductive intentions 12 told could have implantiud removed whenever she wanted a client should know that she is free to discontinue use when desired this is key to free choice could correctly state the maximum duration of implantiud use this indicator verified that clients understood the maximum duration of use ffic composite percentage of fp adopters who responded positively to indicators 3 through 9 these 7 indicators represent the minimum threshold for a client to fully exercise ffic all 7 indicators had to have a positive response for this indicator to be satisfied women who adopted an fp method ffic score average number of indicators 3 through 9 for which the response was positive the average provides a more nuanced view of the differences among servicedelivery approaches the average score provides a more nuanced view of the differences among service delivery approaches abbreviations ffic full free and informed choice fp family planning iud intrauterine device larc longacting reversible contraception sample size the sample size was estimated using client satisfaction as the key outcome of interest although satisfaction is not an ideal measure because of the potential for courtesy bias and subjectivity as an indicator of perceived quality of service delivery 141617 it was one of the only measures we could estimate in advance with relative confidence to calculate sample size assuming that approximately 95 of clients would be somewhat or very satisfied a sample of 73 was adequate at the 95 confidence level to assess client satisfaction at the service modality level historical service statistics helped determine an appropriate sampling interval by facility and service delivery modality in order to reach desired sample size using systematic sampling with a minimum of 73 per service delivery modality the desired sample was then divided across facilities participating in projectsupported mobile outreach or special family planning days during the data collection period the only significant differences between clients attending mobile outreach services and clients at special family planning days were that the women attending special family planning days were older and less likely to have electricity than mobile outreach clients data analysis in tanzania women attending mobile outreach were more likely to have 3 or more children were less likely to own a mobile phone and were more likely to be farmers than women at static services although preference for an implant was not as pronounced as in the drc there was a clear preference for larcspermanent methods among mobile outreach clients compared with static service clients the womens reproductive intentions also varied with 320 attending mobile outreach indicating that they wanted no more children compared with 140 at static services there were fewer differences between users of static and mobile outreach services in uganda than in tanzania and the drc however differences did emerge women attending mobile outreach were more likely to be married or in union had a higher mean number of children had a stronger preference for implants and had a greater desire to have no more children compared with women attending static services method adoption in all countries womens preference for larc permanent methods and especially for implants was reflected in the method adopted significantly higher percentages of women attending nonstatic services in the 3 countries adopted an implant and significantly lower percentages adopted an injectable compared with women at static services few clients in any modality adopted iuds condoms or pills although all of these methods were available at all service modalities in the drc 634 of women attending static services adopted implants and 291 adopted injectables in contrast 942 of women attending mobile outreach and 967 at family planning day events adopted implants whereas only 33 and 17 adopted injectables respectively in tanzania 640 of women attending mobile outreach adopted an implant compared with 460 at static services and only 80 attending mobile outreach adopted an injectable compared with 240 at static services finally in uganda 433 of women attending mobile outreach adopted an implant and 233 adopted an injectable compared with 244 adopting an implant and 511 adopting an injectable at static sites the implant was the method most often adopted in each country and at each service delivery modality with the exception of uganda where slightly more than half of the clients attending static services chose an injectable composite and individual measures of ffic several significant differences were found in elements of ffic between service delivery modalities in each country the ffic composite indicator for all clients adopting family planning showed that fewer than half the clients in any country or for any service delivery modality reported experiencing all aspects of ffic differences between service delivery modalities were significant only in tanzania where 319 of clients attending mobile outreach services reported experiencing all elements of ffic compared with 489 of clients of static services the trend was the same in the drc although the results were not significant in all 3 countries the average number of ffic elements for which the response was positive was between 48 and 61 in tanzania women in static services reported experiencing on average 61 elements of ffic compared with 56 in mobile outreach no other significant differences were found when looking exclusively at larc adopters differences between service modalities were significant only in tanzania 264 of clients of mobile outreach services reported experienc ing all aspects of ffic including additional questions related to larc compared with 407 of clients of static services the directionality of differences in the drc and uganda was the same but again was not significant the average number of ffic elements including larc elements for which the response was positive was between 83 and 98 for all countries the difference was again only significant in tanzania importantly between 927 and 100 of clients who received a family planning method obtained their method of choice in all countries and modalities and the large majority of clients also reported that they made the decision to use family planning either by themselves or jointly with their partner or provider in the drc only 1 individual measure of fficthe client participating in family planning decision makingshowed a significant difference between the service delivery approaches 740 of clients of mobile outreach and special family planning days reported such joint decision making compared with 962 of clients of static services no other individual measures of ffic were significant and there was no clear trend in directionality among the indicators however there was a notable difference in the percentage of women who said that they were given a chance to ask questions less than half attending mobile outreachspecial family planning days compared with 618 at static services it should also be noted that although differences in the ffic composite indicator were not significant only 1 in 5 clients attending mobile outreach or special family planning days reported experiencing all measures of ffic compared with 1 in 2 clients at static services similar to the drc most of the indicators of ffic did not differ significantly by service delivery modality in tanzania the overall trend suggested that ffic was better at static services compared with mobile outreach with 3 individual indicators significantly so reporting that the provider asked about their reproductive intentions reporting that they were counseled on the method received and reporting that they were told where to have their implant or iud other elements of counseling such as counseled on side effects of method received and told could have implantiud removed whenever wanted differed between the 2 service delivery modalities but did not reach the level of statistical significance in uganda only 2 indicatorstold where and when to get an iudimplant removedshowed significant differences both among larc adopters both suggested superior counseling at mobile outreach compared with static services in contrast to tanzania overall where there were sizable differences between the 2 service delivery modalities on indicators that did not rise to the level of statistical significance most measures of ffic were better for mobile outreach services we did not make any statistical comparisons among the countries because their family planning programs are in different stages of development and there were likely differences between populations served however we observed that in tanzania the absolute value of most indicators of ffic was over 80 in contrast many values in uganda and the drc were much lower while variability among different measures was high in the drc measures ranged from 483 for being given a chance to ask questions at outreach servicesspecial family planning day events to 100 for obtained method of choice at static services in uganda the measures ranged from 267 for provider discussed 3 or more methods at static services to 976 for obtained method of choice at static services satisfaction although overall satisfaction did not differ statistically by mode of service delivery in the drc significantly lower percentages of respondents attending outreach servicesspecial family planning days than those at static services reported being very satisfied for 5 of the 8 individual measures of satisfaction amount of time waited amount of family planning information given the opportunity to ask questions the way the client was treated by staff and the way she was treated by the provider for the remaining measures the trend was the same although not statistically significant in tanzania lower percentages of mobile outreach clients than static service clients also reported satisfaction with aspects of services with 3 measures significantly so amount of time waited privacy of consultation and the way the client was treated by staff although overall satisfaction did not differ statistically by mode of service delivery in uganda significantly higher percentages of respondents attending outreach servicesspecial family planning days than those at static services reported being very satisfied on 6 of the 8 individual measures of satisfaction amount of time waited privacy of consultation amount of family planning information given opportunity to ask questions and quality of family planning counseling received and the way the client was treated by staff as stated earlier statistical comparisons were not made among the countries nevertheless it is notable that the proportion of clients reporting being very satisfied in the drc varied widely from just 169 of women attending mobile outreach servicesspecial family planning days for the opportunity to ask questions and 250 for facility cleanliness to 891 at static services for treatment by the provider in uganda there was also pronounced variation with just over a quarter of clients at static services being very satisfied with the amount of time they waited to nearly all clients at mobile outreach services being very satisfied with the way they were treated by the provider in contrast at least 80 of clients reported being very satisfied on every measure in tanzania discussion the analysis of the composite ffic indicator suggests that overall clients experienced greater ffic at static services compared with mobile outreach in tanzania while significant differences were not found in the drc or uganda although fewer than half of clients reported experiencing all aspects of ffic in all countries and for all modalities the ffic mean score indicates that clientsall family planning adopters and larconly adoptersexperienced the majority of elements of ffic the fact that few of the individual indicators of ffic were significant in any country but showed greater differences when examined as a composite indicator may be an issue of power it is therefore important to look at trends in the domains of ffic as well as the composite measure and mean score the results indicate that women were equally likely to obtain a family planning method and specifically the method they wanted at all service delivery modalities in each country it is important to note that a higher percentage of women who came to nonstatic service sites had a preexisting preference for a larc than those attending static services in all 3 countries women coming to nonstatic services may have sought those services specifically because they knew these methods would be available thereby potentially masking a difference in method availability between service delivery modalities the womens preference for larcs at mobile outreach and special family planning days suggests that the high levels of implant uptake at these services were likely related primarily to preexisting preferences rather than the unavailability of other methods or provider bias in particular in the drc the fact that methods were free during special family planning days and mobile outreach may have attracted clients who were waiting specifically for free events in order to obtain larcs which are normally costly findings for the other individual indicators of ffic were mixed one indicator showed better performance at static services in the drc 3 indicators showed better performance at static services in tanzania and 2 indicators showed better performance at mobile outreach in uganda in tanzania the better performance of static services may be a product of the lower volume of clients compared with mobile outreach resulting in longer counseling sessions however we did not measure the length of counseling sessions for each client and therefore cannot be certain of this interpretation in uganda the indicators with better results for mobile outreach services were all related to larcs possibly reflecting that providers who routinely participate in mobile outreach events are more skilled in the provision of and counseling for larcs however the mobile outreach model in tanzania and uganda was similar therefore one would expect similar outcomes it is also plausible that when a client arrives having already decided on a methodwhich was more likely for nonstatic services in all countriesproviders are less likely to give full counseling assumingperhaps incorrectlythat the client has all the information she needs in the drc there was no clear trend indicating that clients at all modalities were equally likely to experience aspects of ffic facilities that provided static services received more routine support and supervision than facilities that held mobile outreach which may have affected outcomes as well though the pattern of impact is not clear questions on counseling specifically asked whether the provider counseled the client about a particular element group counseling is common at mobile outreach services and special family planning day events it is possible that some clients responded no to some elements of counseling because they received information from a different staff member not the provider who gave her the method this may have contributed to the low number of clients at both service delivery modalities in uganda who stated that the provider discussed 3 or more methods with them and that the provider counseled them on the method they received it is common for a provider to review the array of methods available during group counseling whereas the accepted method may be given by a different provider a more nuanced questionnaire could inform this understanding of the data clients attending mobile outreach and special days tended to be of lower ses and education level it is possible that women of lower ses might not understand all of the information during counseling which in turn may have affected their reporting of ffic in practice it is not possible to separate the service delivery modality from the profile of client reached it is therefore important to consider how the client profile may affect ffic in addition to the service delivery modality it is essential to note that even when differences between service delivery modalities were not found some of the indicators of ffic should be improved in all countries and for all modalities for example at least onequarter of clients in each country and for each service delivery modality reported that they were not counseled on potential method side effects in some cases this result may have been because a client was a continuing user of a method however it is important to ensure that all clients are given accurate information about their method options and the benefits and risks of family planning this is particularly true when examining whether clients were given a chance to ask questions although there were no significant differences between modalities in any country uganda was the only country where more than threequarters of clients at any modality reported being able to ask questions all clients should have the opportunity to ask questions despite this nearly all clients received their method of choice the large majority of clients reported independent or joint decision making and there was no indication that any client rights were violated more research is needed to understand why clients may not be experiencing all aspects of ffic and how to better support providers to deliver quality counseling in various service delivery modalities indicators of satisfaction appeared to align with indicators of ffic that is in the modality where clients reported superior indicators of ffic they were also more likely to be very satisfied with various aspects of services and counseling overall this indicates that ensuring that clients experience ffic may increase client satisfaction with services though specific analysis of any such correlation would be needed to investigate this concept further some elements of services that may affect satisfaction such as wait time are beyond ffic and not likely to be correlated the proportion of women reporting being very satisfied with a variety of individual indices was notably low in both service delivery modalities in the drc and uganda suggesting that improvements could be made to all services although no statistical comparisons were made among countries the relatively lower experiences of elements of ffic and of satisfaction in the drc and uganda compared with tanzania is notable it is not possible to extrapolate from these data why this difference occurred however the prevalence of family planning services the maturity of the family planning programs the funding and political environment and other external factors may have affected providers abilities to deliver quality services the implementation of the expandfp program also differed from country to country with varying numbers of providers trained in family planning counseling a different reach of the program and slightly different models for mobile outreach and special family planning days these environmental factors may also affect clients expectations and experiences with family planning services the differences seen in client characteristics between women attending mobile outreach or special family planning days compared with those at static services are also important to consider in terms of the populations reached in the 3 countries findings indicate that overall mobile outreach and special family planning day services reached women of lower ses than static services thus underscoring the importance of nonstatic service delivery options in reaching more disadvantaged and vulnerable populations the lower proportion of women with a history of modern family planning use also indicates that mobile outreach and special family planning days may reach clients with a longstanding across all modalities clients were often not counseled on potential side effects or given the opportunity to ask the provider questions unmet need particularly an unmet need for limiting childbearing these differences in characteristics indicate that mobile outreach and special family planning days are important strategies for increasing access to family planning moreover the higher comparative uptake of larc by women attending mobile outreach and special family planning days and the possibility that many women came to these services with these methods already in mind indicate that nonstatic services are important ways to increase access to these underutilized methods for underserved populations the womens ses may have also affected how providers counseled them andor how the clients experienced understood and recalled that counseling further research is needed to explore the reasons for differences in ffic and to determine what approaches may effectively ensure that providers enable all clients especially women of lower ses to make ffic it is equally important to ensure that the various service delivery modes including those crucial to reaching underserved populations with underutilized methods expand access to family planning while offering quality counseling and ffic for all clients existing tools that can be used to monitor and improve clients experiences of ffic can and should be brought to scale at national levelsacross the private public and nonprofit spheresand used to continually improve services additionally clientprovider interactions can and should be tailored to meet individual client needs some clients may want more information than others returning clients may be happy with their method and not need or want counseling on other methods while others may want to hear about an array of options qualitative research on both the client and provider experiences with counseling can help program planners and implementers to better understand these dynamics and how to measure them observations of clientprovider interactions are also important to understand the reasons why some clients had better experiences with some elements of ffic than others limitations this research is not generalizable at the country level because the facilities which were purposively selected in each country received different levels of project support and therefore are not representative of facilities in general similarly publicsector mobile outreach may differ from privatesector or ngoled outreach which was not captured here and the client profile at study facilities may not be representative of clients in general additionally the studys findings are dependent on client recall of experiences recall bias was minimized by interviewing clients immediately following their receipt of services and prior to their exit from the facility this was a strength of our study design compared to household surveys which interview clients about counseling practices long after the event has occurred courtesy bias may also have affected the reliability of study results especially related to measures of satisfaction this bias was minimized by interviewing clients privately and by nonfacility staff conducting the interviews in addition measures of the elements of ffic were limited in our study to the clients perspective finally the relatively small sample size may have limited the power to detect significant differences in particular because the desired sample size was not reached in all modalities conclusions the study findings suggest that client experiences of ffic elements varied among the service delivery modalities with certain elements scoring lower and other elements scoring higher at some nonstatic service delivery modalities compared with static services the reasons for this variance may be related to client volume during nonstatic service delivery events the profile of clients who attended nonstatic service delivery differences in how providers approached women of higher or lower ses or other unknown factors in cases where the ffic scores were lower provider monitoring supervision and follow up on appropriate counseling methods as well as ensuring sufficient staff time for comprehensive counseling may have enhanced clients satisfaction and experiences of ffic implementers may need to increase staffing establish a maximum number of clients during special family planning events or use other approaches to ensure enough time for counseling further research is needed to understand the conditions or circumstances that may make ffic more difficult in mobile outreach settings or during special family planning days special family planning days and mobile outreach days play a key part in expanding access to family planning and the large majority of clients were able to obtain the method of their choice in these events the majority of whom chose a larc each service delivery modality poses different challenges to providers to provide quality services and counseling and these must be accounted for in program planning despite some high scores most elements of ffic for all service delivery modalities and in all countries still showed room for improvement women who adopt family planning should receive highquality care including ffic this study shows the importance of monitoring ffic as programs expand access to family planning services and methods it is not enough to reach clients with methods and services clients should be empowered to make decisions fully freely and with correct and complete information competing interests none declared

in all 3 countries nearly all women obtained their method of choice with more mobile outreach and special family planning day clients having a preexisting preference for implants than static service clients clients of all service modalities in all countries reported experiencing most elements of full free and informed choice but there is room for improvement with some aspects such as counseling about potential side effects and giving clients the opportunity to ask questions résumé en français à la fin de larticle

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background with the proliferation of global migration increasing attention is being paid to health outcomes of immigrants in developed countries immigrants tend to arrive with better health than their native born counterparts this healthy immigrant effect has been demonstrated across multiple health systems in several countries and for a number of conditions 1 2 3 4 5 6 7 with increasing duration of residence in a host country this health benefit can shrink as immigrants adopt behaviours and exposures more similar to the native population this latter observation demonstrated in adult populations has been termed the convergence hypothesis 489 the notion of the healthy immigrant effect has been less well studied in children and young adults but has been shown for immunizations 10 mental health 111 and substance use 1 the convergence hypothesis however has not been evaluated at a populationbased level for pediatric health outcomes moreover in adults there is considerable variation in the effects of immigration on health and its subsequent convergence towards the native population depending on the health outcome and region of origin 89 injury remains one of the leading causes of death hospitalization and emergency department visits for children and youth in north america and europe 1213 most injuries are preventable and injury reduction strategies when targeted and implemented appropriately are successful 14 15 16 immigrants have a lower risk of unintentional injury than canadian born children 17 18 19 though there is some causespecific variability this has been demonstrated across all causes of injury 19 the evidence for the extent to which the lower risk of injury persists with increasing duration of residence in a new country for children and young adults from immigrant families is not known as immigrant populations acculturate their risktaking behaviours or exposures may change investigating patterns of injury across immigrant populations with increasing time since migration can help provide a more comprehensive picture of contributing factors to injury risk in this large and growing population with better understanding of unintentional injury risk in immigrants strategies can be developed for injury prevention education behaviour modification and policy development so that immigrants can maintain their health advantage we sought to examine patterns of unintentional injury in children and youth from immigrant families in a large diverse canadian province with a single payer health care system where 20 of the population are immigrants 20 our specific objectives were to describe the epidemiology of unintentional injuryrelated emergency department visits hospitalizations and deaths overall and according to cause of injury in recent intermediateterm and longterm children and youth from immigrant families and by region of origin and to test the association of unintentional injury and duration of residence and region of origin in children from immigrant families in ontario canada methods study design this populationbased crosssectional study was carried out at the institute for clinical evaluative sciences using multiple linked health and administrative databases through a research agreement with the ontario ministry of health and longterm care research ethics board approval was obtained from the hospital for sick children and sunnybrook health sciences centre in toronto ontario dataset sources the ontario health insurance plan is the singlepayer universal funding plan for medically necessary physician and hospital services in ontario permanent residents admitted to canada as immigrants or refugees are typically eligible for ohip within 3 months of living in ontario ohip eligible persons are entered into ontarios health care registry the registered persons database which contains sociodemographic information about residents including their age sex and postal code their ohip number is encoded and linked to a number of other health administrative and demographic databases the canadian institute for health information discharge abstract database and national ambulatory care reporting system provide standard data collection and reporting tools to capture hospitalization and emergency department visit information respectively and include the main diagnosis linkage rates to the rpdb are greater than 97 21 these were used to obtain injuryrelated information where a hospital or ed visit occurred the ontario registrar general death was used to identify in and out of hospital injuryrelated deaths in ontario neighbourhood income quintile was obtained using statistics canadas postal code conversion file to link a patients postal code at the dissemination area level based on the 2006 canadian census 22 the permanent resident data system a federal database maintained by immigration refugees and citizenship canada holds sociodemographic and immigration information on all permanent residents landing in ontario from january 1 st 1985 to the present permanent residents are immigrants who have been granted to the right to stay and work in canada without limitations on their stay it does not include data on temporary or undocumented immigrants information is collected from official immigration documents upon landing the mombaby database is an ices derived database that pairs all mothers with their newborns delivered in hospital in ontario through linkage of the cihidad inpatient admission records of delivering mothers and their newborns 21 this was used to identify newborns born in canada to immigrant mothers study population the study population included children and youth from birth to 24 years of age who were immigrants or were born in canada to immigrant mothers to be included individuals must have had an ircc permanent resident record or be the child of a mother with an ircc record and have a linked motherbaby dyad in the ices mombaby database maternal immigrant status was included to reflect the influence of family immigrant status rather than that of only the child parental health and risktaking behaviours are particularly important for a childs risk of injury moreover maternal immigrant status is associated with risk of injury in children 1923 individuals must have been residing in ontario with a valid ontario health insurance plan number between january 1 st 2011 and december 31 st 2012 outcome measures the main outcome measure was an unintentional injuryrelated visit to an ed or a hospitalization or an unintentional injury related death during the study window the international classification of disease 10cm external cause of injury codes were used to identify and group injuries by cause 24 multiple events by the same patient were included although only one event per patient per day was included where individuals had an ed visit with a subsequent hospitalization only the hospitalization was counted duplicate overlapping or transferred ed visits were not double counted so that only the first record for any given injury event was considered exposure variables the main exposure was duration of residence in canada immigrants were grouped as recent intermediateterm and longterm duration of residence was determined from the difference of the number of years from the date of landing to december 31 st 2011 if the patient was born in canada to an immigrant mother the duration of residence was calculated based on the maternal immigration information the secondary exposure was region of origin based on the country of birth using modified ircc region groupings 20 covariates a number of covariates that have been shown to be associated with risk of unintentional injury were considered older age is a strong predictor of injury risk as is male sex 1725 both age and sex were therefore included as covariates in a number of populations low income has been associated with an increased risk of both unintentional and intentional injury 2326 we therefore included postal code based neighbourhood income quintiles within dissemination areas from health records as a covariate statistical analysis descriptive statistics were performed for the main independent variables outcome variables and covariates the crude injury rates were calculated as were the total number of events to compare outcomes of immigrants by duration of residence multiple variable poisson regression models adjusting for overdispersion were used to compute rate ratios with 95 confidence intervals a sensitivity analysis excluding children and youth of immigrant mothers was also performed for each model variables were selected a priori and included in the regression analysis the causespecific rate ratios of injury by duration of residence was also calculated using multiple variable poisson regression models adjusting for overdispersion all results there were 999 951 children and youth included in the study compared with longterm immigrants recent immigrants had a greater proportion of young and lower neighbourhood income quintile individuals most immigrants were from south and east asia the annual crude rates of unintentional injuries per 100 000 were 6830 for ed visits 151 for hospitalizations and 4 deaths table 2 shows the rates of unintentionalinjury events by duration of residence and region of origin compared with recent immigrants immigrants living in canada for more than 10 years had higher rates of ed visits and hospitalizations for injuries across all age groups income quintiles and regions of origin with the exceptions of hospitalizations among 10to 14yearolds and central americans and emergency department visits among those from south america where rates were relatively unchanged immigrants from east and south asia had the lowest rates of unintentional injury and those from the united statesunited kingdomeurope central asia and south america had the highest rates in the multiple variable poisson regression model after adjusting for age sex income quintile and region of origin recent immigrants had significantly lower rates of unintentional injury and this risk increased over time sensitivity analysis excluding children and youth born to immigrant mothers excluding infants less than one year and excluding those with missing region of origin showed figure 2 shows the causespecific risk of unintentional injury by duration of residence in canada longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object scald burns machineryrelated injuries nonmotor vehicle bicycle and pedestrian injuries the risk of these latter injuries did not change significantly with increasing duration of residence in canada moreover risk of injury was highest in recent immigrants for drowning in evaluating causespecific injury by severity similar patterns by duration of residence were observed in causespecific rates of injury discussion in this large populationbased crosssectional study we report longer duration of residence in canada is associated with an increased risk of unintentional injuries in children and young adults from immigrant families this was observed across most causes of injury except for drowning and scald burns where the highest rates of injury were among newcomers risk of unintentional injury was lowest in immigrants from south and east asia and highest in those from europe and the americas the rates of unintentional injury in our cohort of immigrants are much lower than published rates for pediatric injuries in the general child and youth population of ontario 17 supporting a healthy immigrant effect our study is the first to report a loss of this health advantage over time with immigrant injury risk converging towards levels of the general canadian population this is particularly important given the amenability of injury risk to appropriately targeted safety interventions 13 the shrinking health benefit of immigrants over time may be explained by a number of factors as immigrants acculturate they may introduce changes to their parenting style including direct supervision of children with settlement and integration children and youth may have increased exposures such as more time spent in motor vehicles with less time spent exploring urban areas as pedestrians the worsening injury rates in immigrants may reflect adoption of unhealthy risk taking behaviours known to contribute to injury such as drug and alcohol use 13 or involvement with gangrelated firearm violence 2728 there may also be changes in access to primary care which has been shown to be worse over time from migration 29 this may reduce opportunities for preventative counselling on injuries and safe play over time in canada similarly barriers to careseeking including initial distrust in or use of the health care system may preclude recent immigrants from visiting a hospital for injuries conversely our findings of increasing falls cuts and overexertion may indicate improved access to play spaces with increased physical activity or participation in sport by immigrants as they integrate into life in canada the observed rates of causespecific injuries by duration of residence are not unexpected research from denmark has shown that while pediatric immigrants have lower risk of injury a higher proportion scald and hot oil burns occurred in immigrants compared with native danes 23 more time spent at home cooking and preparing foods by immigrants especially within newcomers may explain this finding drowning rates among newcomers may be related to lack of knowledge about safe swim environments and highlights an area in need of intervention relatively high rates of suffocation were observed in recent immigrants recent immigrants may have inferior understanding of north american or european product safety guidelines such as crib safety all of which can lead to entrapment or strangulation and subsequent suffocation 13 understanding the variability in the influence of duration of residence over time on causespecific injuries will be important to study as injury prevention strategies are developed for example the unchanged rates of bicycle pedestrian and machinery injuries may reflect the countering protective effects of being a recent immigrant and changes in exposures over time in canada this remains to be studied we observed significant differences in risk of injury by region of origin in particular south and east asian immigrant populations had very low rates of injury others have described significant variability in rates of injury mortality by region of origin 5 though comparisons to asian immigrant populations have not previously been reported interestingly south and east asian immigrants have among the highest incountry unintentional injury rates across the globe with rates second only to african countries 13 clearly this risk is not brought with them through immigration our observations may be related to selection factors in those who immigrate to canada as well as cultural differences in risk taking behaviours and exposures that reduce overall risk of unintentional injury upon arrival in canada strengths and limitations this is the first study to report injury risk by duration of residence in a host country the large sample size which included the vast majority of immigrants to ontario and the use of health services data to ascertain an injury event sets this study apart from other injury studies which have much smaller sample sizes 30 31 32 or rely on selfreport which can bias results especially for injury reporting 33 the findings may be generalizable to many developed regions including the united states australia and the european union where large proportions of the population are foreign born from a wide variety of countries with similar immigration policies and comparable safety standards however there are a number of important limitations to our study as it is based on registry data this precludes our understanding of circumstances that may have contributed to injury events other demographic information such as family education level or paternal immigrant status may have also helped to better understand injury risk over time our database does not include temporary or undocumented immigrants and may not be generalizable to these groups immigrants who migrate to ontario after landing in another province are misclassified as nonimmigrants and are not included in our study finally linkage of the ircc database to rpdb is not perfect with a higher proportion of nonlinked immigrant populations from asia where common names make accurate linkage more challenging 27 conclusions the risk of allcause and most causespecific unintentional injuries in immigrant children and youth rises with increasing duration of residence in canada this important finding indicates there is a need to understand why this is occurring and to develop strategies which may include providing education about water and cooking safety for recent immigrants to maintain the immigrant health advantage over time after migration this must be done while balancing the desire to support active living and healthy child development additional files additional file 1 table s1 immigrant children and youth in ontario by duration of residence 2011 to 2012 table s2 rate ratios of unintentional injuries for immigrant children and youth aged 024 years by duration of residence 20112012 descriptive table of cohort of immigrants excluding children and youth born to immigrant mothers and table of adjusted rate ratios testing the association of duration of residency in canada and risk of unintentional injury excluding children and youth born to immigrant mothers additional file 2 table s3 children and youth from immigrant families in ontario by duration of residence 2011 to 2012 financial disclosure all authors have no financial relationships relevant to this article to disclose competing interests the authors declare that they have no competing interests

background immigrants typically arrive in good health this health benefit can decline as immigrants adopt behaviours similar to nativeborn populations risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration we sought to examine the association between duration of residence in canada and risk of unintentional injury methods populationbased crosssectional study of children and youth 0 to 24 years in ontario canada 20112012 using linked health and administrative databases the main exposure was duration of canadian residence recent 05 years intermediate 610 years longterm 10 years the main outcome measure was unintentional injuries causespecific injury risk by duration of residence was also evaluated poisson regression models estimated rate ratios rr for injuries results 999951 immigrants were included with 242 recent and 264 intermediate immigrants the annual crude injury rates per 100000 immigrants were 6831 emergency department visits 151 hospitalizations and 4 deaths in adjusted models recent immigrants had the lowest risk of injury and risk increased over time rr 079 95 ci 077 081 recent immigrants rr 090 95 ci 088 092 intermediate immigrants versus longterm immigrants factors associated with injury included young age 04 years rr 130 95 ci 126 134 male sex rr 152 95 ci 149 155 and high income rr 093 95 ci 089 096 quintile 1 versus 5 longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot objectscald burns machineryrelated injuries nonmotor vehicle bicycle and pedestrian injuries the risk of these latter injuries did not change significantly with increasing duration of residence in canada risk of drowning was highest in recent immigrants conclusions risk of allcause and most causespecific unintentional injuries in immigrants rises with increasing time since migration this indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration active living and healthy child development

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including obesity noninsulin dependent diabetes and dental caries 2 a history of colonisation governmentenforced assimilation racism and cultural annihilation has had profound impacts on indigenous health and is reflected in health inequities sustained by indigenous communities today 3 4 5 the forcible removal of communities from traditional lands loss of traditional customs and languages and subsequent environmental dispossession is an additional contributing factor to poor health because it has resulted in a transition from nutrientdense traditional foods to processed nutrientpoor western foods that are high in sugar 67 in australia aboriginal andor torres strait islander communities flourished for 65000 years prior to european invasion and colonisation 8 economic and social discrimination processed diets infectious disease environmental dispossession and child removal are some of the ways in which processes of colonisation and government policies have intentionally disrupted indigenous health in australia 9 despite the australian governments considerable resources allocated to addressing health inequities between indigenous and nonindigenous australians disparities continue to escalate 1011 in australia 61 of indigenous children experience decay in their primary teeth compared to 41 of nonindigenous children and indigenous children are more likely to have untreated decay in at least one primary tooth than nonindigenous children 12 the deleterious impacts of poor oral health in children are well documented pain speech difficulties lowered selfesteem and difficulty eating or sleeping are common consequences of ecc 13 evidence suggests that more severe consequences impact childrens growth development concentration education attainment quality of life failure to thrive and can be lifethreatening in some cases 14 15 16 17 18 while ecc can have serious ramifications on health the disease is entirely preventable with limited sugar consumption proper oral hygiene regular dental visits and sufficient fluoride exposure 18 19 20 childhood dental disease is the strongest indicator for adult dental disease 1621 and the greatest impact on childhood oral hygiene practices is caregiver influence underscoring the importance of prevention efforts aimed at young children within the family setting 182223 varying degrees of success have been experienced with populationlevel interventions for oral health with water fluoridation being one of the most successful interventions in reducing ecc to date 2224 despite fluoridation and educational programs for children and parents barriers to oral health prevention persist for indigenous communities as evidenced by the prevalence of ecc among indigenous children 25 in 2007 an australian public service report detailed indigenous health as a wicked problem difficult to solve and symptomatic of deeper concerns 26 present prevention strategies and policies do not consider the impact of issues such as colonisation or structural barriers that indigenous peoples face in establishing good oral health 927 developing contextual understandings of the environments in which these health inequities persist is necessary when addressing such vast disparities 28 qualitative research offers an opportunity to further explore the experience and context of poor oral health among indigenous peoples that has been extensively documented by quantitative findings therefore the aim of this paper is to explore the complex context in which indigenous australians experience oral health collate and interpret participants experiences and develop an understanding of current barriers impeding parental efforts to establish oral health practices for their indigenous children methods method motivational interviewing is a psychotherapy intervention that encourages participants to identify explore and resolve obstacles to behaviour change 29 contrary to traditional health education approaches mi is an empathetic behavioural support method rooted in the notion that knowledge alone is insufficient to elicit behaviour change and that intrinsic motivation increases likelihood of behaviour change mi creates an exploratory atmosphere for participants to articulate personal values capacities and motives for behaviour change emphasising an individuals personal motivation for change 30 mi has previously been used to elicit oral health behaviour change for parents and their children 3132 importantly mi parallels cultural values of indigenous peoples including oral traditions of storytelling and yarning 33 respects selfdetermination and is better able to yield a holistic and contextual understanding of a given issue 3435 design this project was nested within a randomised control trial of an ecc intervention designed and conducted in partnership with indigenous families and communities in south australia the protocol 36 primary quantitative results 37 and cohort profile have been published 38 at baseline the trial enrolled 448 women pregnant with an indigenous child across south australia participants were randomly allocated to intervention or control groups there were four components to the intervention provision of dental care to mothers during pregnancy application of fluoride varnish to the teeth of children anticipatory guidance and mi the findings presented in this paper are derived from the mi element of the trial motivational interviews were conducted with participants in the intervention group at baseline during pregnancy and when the child was aged 6 12 and 18 months the respective directives for each session were encouraging dental care during pregnancy emphasising the importance of noncariogenic foods and drinks for children emphasising the importance of fluoride in ecc prevention encouraging first dental appointment participants in the control group received mi at 24 30 and 36 months with the first session combining directives one and two participants and sampling for this qualitative analysis we utilised purposive sampling of motivational interviews based on the fidelity scores of trained staff who conducted the mi fidelity is defined as the extent to which an intervention is performed as intended 39 fidelity assessment of mi was completed to ensure sound methodological approach and scientific rigour in this trial 40 the success of mi is contingent on interventionist competency and fidelity in eliciting participant statements of selfmotivation and resistance to change 41 four trained staff conducted motivational interviews with varying compliance to the mi approach and different degrees of participant engagement all included interviews for this analysis were completed by the single staff member that had the highest mi fidelity score this decision was made because these interviews provided the richest data constituted the majority of collected data and interviews were more comparable with one another than across interviews by other staff which facilitated analysis the staff with the highest fidelity score is a senior indigenous researcher who utilised colloquial language and established trusting relationships with participants analysis it is important to acknowledge the assumptions one brings to qualitative research as they inescapably impact the interpretation of data and production of findings 42 as a nonindigenous researcher from canada the primary author took steps to familiarise herself with the data and the context in which it was collected prior to analysis local contextual and cultural understandings were enhanced through field work with the same communities and indigenous health workers involved with this trial approximately one year was taken in reviewing reading and listening to interviews understandings of data were extensively discussed with the senior indigenous researcher who conducted the interviews and the projects primary investigator prior to initiating analysis braun and clarkes 42 43 44 framework for reflexive thematic analysis guided the analytic process reflexive thematic analysis embraces the unique subjective skills a researcher brings to the project and enables organic identification of themes 42 inductive themes grounded in the data were coded line by line with nvivo 12 software and without a structured codebook to provide space for engaged interpretation of data once all transcripts had been coded the data was revisited and similar codes were aggregated for iterative thematic development typically reflexive thematic analysis does not utilise summary topics in conceptual models 42 however due to the quantity of codes themes and transcripts analysed as well as the multifaceted context of indigenous oral health they are employed here to make sense of the ways in which barriers exist for participants the data from 357 interviews and 227 participants provided a unique opportunity to explore how socioeconomic positions might contribute to oral health experiences for carers subgroup comparisons were based on maternal age residential location number of children in care and employment status these characteristics were chosen because the australian institute of health and welfare estimates that 34 of the health gap between indigenous and nonindigenous australians is attributable to social determinants of health including income employment and overcrowding 45 and in 2018 indigenous mothers in australia were most likely to be aged between 20 and 24 46 the nvivo software attribute feature was utilised to assign characteristics to participant transcripts and thematic codes matrices were utilised to compare the relationships between participants and themes demographics and participants and demographics and themes subsequent analysis determined how many participants within each demographic subgroup discussed a given theme results respondents discussed a number of factors that create barriers for participants to establish oral health practices these included knowledge factors parental factors structural factors and social factors the findings below are presented in order of highest to lowest frequency that respondents mentioned a particular theme knowledge factors parental factors structural factors and social factors findings represent discussions from 357 interviews with 227 parents or carers of indigenous children aged 636 months from across south australia participant characteristics varied across the included demographic measures of employment number of children in care residential location and maternal age the majority of the sample were older than 25 had 13 children in their care were unemployed and resided in metropolitan areas knowledge factors knowledge was discussed by participants as critical to ensuring strong oral health practices for their children with many individuals desiring more education or knowledge in specific areas limited nutrition knowledge was a prominent theme across all interviews and all participants generally there were a lot of misconceptions about what is healthy for children he does have chocolate but i only give him the kinder surprise chocolate because its got more of the milk in it further discussion with parents revealed that a lot of this confusion was confounded due to misleading nutrition marketing and resulting nutrition assumptions baby food is advertised as being good for your baby and healthy for your baby and a lot of them claim … its pure fruit no added sugar… thats a bit sad because a lot of mums especially when youre shopping youre busy you go well this is supposed to be healthy for my baby its on special im going to chuck it in my trolley and not realising that it could be doing more harm than good many parents cited front of pack marketing as a key information source in terms of nutrition decisions made for their children when parents were asked to order baby food from highest to lowest according to sugar content almost all parents who did not read the nutrition label ranked items based on nutrient claims included on product packaging specifically no added sugar many carers were taken aback when they discovered that the baby food with the no added sugar claim was the highest in sugar that s disgusting they shouldnt be able to make things like that they should have a big sign on the front with high sugar content like they do with smoking limited oral health knowledge concerning topics such as when children should have their first dental visit when to start using a toothbrush and how much toothpaste is safe for children was common can you brush his teeth too much is there a limit to how many times we can brush their teeth during the day many parents were confused or did not have the correct oral health knowledge how would you go about getting the bugs and sugar off his teeth after hes had a bottle and hes sleeping i really dont know i would just assume that the saliva will wash it away when hes sleeping fluoride knowledge was highly varied with some parents identifying fluoride as cancercausing a whitening agent or a caffeine source the initial interview for the intervention group occurred during pregnancy and many mothers had misinformation around dental visits during pregnancy worrying that it could put their baby in harms way once this was clarified and mothers understood that dental visits were safe many were willing to go even if they had not been in years poor parent oral health practices as a result of limited oral health knowledge were discussed as a barrier to establishing child oral health some parents shared that they cannot expect their children to brush their teeth or reduce sugar consumption when their own actions contrast these expectations some parents identified dental visits as low priority because its something ive never done or i just dont feel like it other parents discussed oral health as a lower priority amongst competing obligations this notion provides insight to the practice of only using dental care for emergencies i think well probably just go to the dentist when he starts to get holes in his teeth or if his teeth are hurting or something fell out or if hes fallen down and lost his tooth and probably then i would take him to the dentist thats what i did with all the other ones when they start to get holes or they need something done to their teeth thats when i take them to the dentist shock at amount of sugar in baby food misleading nutrition marketing and nutrition assumptions were the knowledge factors discussed by the highest number of participants these themes were mentioned most frequently by metropolitan families families with one to three children and unemployed parents parental factors parental factors relate to barriers associated with selfidentified habits feelings or justifications contributing to debilitating oral health habits the majority of parents identified sugar consumption as detrimental to their childs oral health and then utilised concepts including flavour enhancement sugar cravings and treating with sugar as justification for exposing their child to sugar parents commonly described adding sugar to cereal or water for children to make it taste better sugar cravings were discussed in terms of parent addiction as well as children children would often cry or throw a tantrum until parents succumbed to the childs demands some parents justified giving sugar because of their cravings you cant expect them to give up because im addicted to coke you know so just give it using sugar to spoil children was common even for children who were not yet on solids i only give her honey on the dummy every now and then because i like just to give her treats but its not all the time many parents were actively trying to wean children from nighttime bottles more so due to worries about choking or misalignment of teeth rather than dental decay prevention numerous parents talked about caving on bottle removal attempts often because of the comfort associated with the bottle it seems to be her comfort thing for her bed like shes got a blanket but well shes got a room full of toys too but she seems to like just to lay down and drink a bottle and just play with my hair and thats how she goes to sleep so i dont really want to take it away from her because thats her comfort thing convenience of bottles was another barrier to reducing bottle reliance its bad but theres nothing i can do about it unless i dont want to get any sleep a lot of parents were hesitant to wipe their babys teeth after feeding because they worried they may disturb the babys sleep limited time or energy was another barrier some parents mentioned they had been feeling slack and brushing teeth making food at home or other preventive behaviours were not their primary concern hes very fullon so i just feed him and then do my washing and then after the washing hes probably in something doing something and its just too fullon to be able to read nutrition labels if it had on the front of the packaging how many tablespoons of sugar id probably think a second about getting him certain things but it doesnt people dont have time to read that the mums that i know… they just go for whats easy the convenience of processed foods and sugar were discussed as a factor of limited time and the easiest option especially when at sporting or social events and when travelling i have tried a few of these baby foods when were travelling because they made it quite handy to keep in the esky and just whip it out to give her something for parents who identified low water consumption in their children the two primary barriers were child aversion to water and low household tap water use some households used rainwater as their primary source of water usually due to access and taste preference limited time or energy exposure to sugar and comfort of bottle were the parental barriers discussed by the highest number of participants these three themes were cited most frequently by families in nonmetropolitan areas families with one to three children unemployed parents and older parents structural factors physical distance from dental providers as well as long wait times were structural barriers for families with mothers waiting between eighteen months and eight years for a public dentist appointment many participants discussed a fear of dental visits as a barrier to booking and attending appointments several parents were under the impression that school dental visits common in primary schools across australia were sufficient in place of regular dental checkups this assumption prevented parents from taking their children for dental visits and waiting until the child was at least 5 years old and eligible for the school programs while this program intends to facilitate strong oral health it created confusion for participants around when to access dental services for their children in kindy they take kids to the dentist and stuff i just thought when they go to kindy they usually send home a note saying theres a dentist coming is it alright if they can see you the dentist comes and if the dentist says theres any problems thats when ill take them to the dentist i never thought about taking her before… i thought all kids just went to the dentist when they went to school financial limitations were discussed in terms of the cost of dental care and transportation to appointments when participants were informed about funding schemes or offered transportation to dental visits many that had previously been unable to go were happy to attend parents cited previous negative healthcare experiences as a barrier to pursuing preventive healthcare and these experiences directly influenced parental perceived negative reaction of children at their first dental visit specific stories of negative dental experiences were shared and a few parents discussed experiences of racism ive noticed with when you go to doctors and all that … like dentists especially being a black woman they dont talk to you they talk to the secretary or whatever it is about you and then youve got to remind them hello im sitting in the room you know youve got to kind of put your foot down… i think that they think that i dont know what … theyre talking about you know… i want to be treated with the proper respect that everybody else gets because you can see it when you walk into the doctors they look at you like oh another black person the structural component of sugar consumption related to the sheer availability of sugar the industrialisation of food production has rapidly transformed the food landscape for communities especially for those in rural and remote areas where reliance on processed foods have increased due to limited access to fresh foods parents expressed being overwhelmed at the availability of sugar and exhaustion at navigating which foods are healthy for their families its terrible its just in everything sugars in everything and like i said you know some things you think theres not much sugar in them but its you know right at the top of the ingredient list parent perceived negative reaction of child at dental visits availability of sugar and financial limitations were the structural barriers cited by the greatest number of families lack of transportation was only mentioned as a barrier by unemployed parents and experiences of racism when accessing health services was only mentioned by employed parents social factors social factors were concerned with community and social environments in which oral health exists limited family support was a barrier for parents who needed help with transportation or babysitting for dental visits some parents touched on the difficulty of maintaining oral health when extended family assist with childcare but do not respect their routines parents with limited partner support described the burden of responsibility for all aspects of their childrens lives which often resulted in a lowered priority for oral health limited partner support was also discussed as poor communication or respect between parents regarding oral health routines lack of oral health social discussions at parent support groups or among friends was commonly discussed household role models including parent and sibling negative influence were identified as barriers to establishing oral health practices for children parents identified themselves as a negative influence with regard to sugar consumption saying that they couldnt justify limiting their childrens sugar when they were addicted many parents described letting older children have sugar which frequently resulted in the taunting of younger child or sneaking them lollies sugar consumption was heavily impacted by social settings and special occasions family members giving sugar was the most common theme within social factors parents expressed frustration at family members disobeying their wishes and overriding their efforts to restrict sugar consumption parents suggested that giving sugar was a way for relatives to show their love but many families dismissed the potential impacts on the childs health some parents even talked about staying at home more often to control sugar consumption when we go to my mum and dads its like because my other nephew is there and theyve got sugar … and baby goes whats that so thats why we try and stay home family members giving sugar was the social barrier cited by the highest number of participants across all subgroup characteristics younger parents and those in nonmetropolitan regions frequently discussed the barrier of negative sibling and parental role model families in metropolitan regions most frequently discussed sugar on special occasions and a lack of social oral health discussions discussion indigenous oral health inequities in australia are well documented 415161822 47 48 49 however few projects have highlighted indigenous voices and documented personal perspectives providing context for the experience of indigenous oral health in australia 27 50 51 52 53 this project is unique in that it employed an openended approach to discussion through the use of mi and provided space for participants to ask questions and direct the conversation 30 the results emphasise the multifaceted circumstances in which indigenous oral health exists for new mothers and their childrenwith identification of barriers across parental structural social and knowledge factors many findings from this project reinforce previously identified barriers to oral health for indigenous communities including availability of sugar 1851 inaccessibility of oral health care 152754 racism 275255 poor parent oral health practices 535657 lack of accessible transport 275257 limited time and energy 50 competing health priorities 275051 waiting times 2752 financial limitations 27 5052 55 58 school dental programs 5052 limited oral health knowledge 275354 and limited nutrition knowledge 5152 findings of selfidentified poor parent oral health practices fear of dentist waiting lists physical distance from dentist financial limitations negative health care experiences and limited oral health knowledge work together to tell an important story that parents shared during this project the impact of these factors results in low dental attendance and lack of emphasis on prevention which is alarming because regular dental visits increase the probability of diagnosing managing and limiting oral disease 59 similarly butten et al 51 found a lack of prevention efforts amongst indigenous mothers in queensland due to the complex interplay of financial personal and structural factors the availability of school dental programs shaped parents perceptions of child oral health needs in this project which limited prevention efforts as parents did not identify a need to take children for dental visits earlier for many fiveyearold children it is too late for preventive actions and restorations are needed indigenous mothers in queensland utilised school dental programs for older children but many did not take their preschool children for dental visits 50 regular dental attendance and prevention efforts underscore healthy trajectories behaviours and improved quality of life for children 59 60 61 indigenous children have the highest rates of dental surgery under general anaesthesia and the occurrence is increasing in australia indigenous children have twice the rate of hospitalbased dental surgery under a general anaesthetic compared to nonindigenous children 47 the high cost risks and logistical implications of dental surgery as well as recurrence of disease provides precedence for the prioritisation of prevention over treatment of ecc 13 additionally prevention is the most costeffective mechanism to addressing ecc with research suggesting that fifty dollars is saved on restoration procedures for every dollar spent on prevention 62 findings from this project are representative of carers with children 36 months and younger indigenous mothers from queensland have described the increased difficulties experienced when trying to maintain oral health routines as children age which further stresses the importance of establishing good oral health habits at a young age 50 limited parental oral health knowledge impacts a childs oral health due to the close relationship between caregiver oral health and child oral health 18 both parent tooth brushing habits and attitudes or knowledge towards oral health have been associated with ecc development in children 6364 limited oral health knowledge directly impacts child health as poor maternal oral health is related to adverse birth outcomes 65 this trial encouraged pregnant mothers to attend dental appointments and to take children around 18 months of age limited oral health knowledge persisted among participants who attended dental appointments highlighting the importance of sustained awareness efforts and behaviour change programs for oral health prevention dental services are not covered for adults under medicare the public funding system in australia while a public dental service exists they are stipulated by eligibility criteria and often have long wait times and private options require large outofpocket fees 66 our findings highlighted common misinformation around dental visits during pregnancy current evidencebased guidelines recommend that women seek dental care early in pregnancy and identify the importance of midwives in facilitating this however access for many pregnant mothers remains low 5267 previous research suggests that lack of referral knowledge and competing health matters are barriers to prioritising oral health for midwives in australia 68 and limited oral health training exists for aboriginal health workers 27 mandating oral health education for all health professionals has been suggested as a way to increase accessibility of oral health 50 the importance of culturally appropriate ongoing and informal dissemination of oral health information has been noted elsewhere 5254 and the lack of social oral health discussions identified by participants in this project reinforces the need for communitylevel education and health promotion knowledge factors also extended to nutrition knowledge in our project misleading nutrition marketing nutrition assumptions shock at amount of sugar in baby food and not reading nutrition labels were all findings related to limited nutrition knowledge limited knowledge in conjunction with other factors such as limited time or energy convenience of processed foods financial limitations and availability of sugar resulted in a constrained ability of parents to make healthy food choices for the majority of parents in our project nutrient claims were the primary source of nutrition information and largely influenced food decisions many parents were upset once they realised the nutrition assumptions that they had made due to misleading marketing similarly indigenous mothers in queensland identified that they had done the wrong thing by giving children milk or juice because they believed it was healthy the concept of a health halo has been reported in previous research and occurs when nutrient or health claims lead to consumer interpretations of a product being healthier than it actually is 69 in our project one parent suggested using warning labels for high sugar content similar to cigarette packaging a first nations participant in a canadian study suggested the same idea … t he same scope of thinking like they do with cigarettes they should put warning labels on the candy bars 54 the relationship between these factors underscores the importance of nutrition education for parents and consideration of the impact that nutrient claims on baby foods have on nutrition assumptions and food choices stronger regulation for claims using nutrient profiling has previously been called for in australia due to consumer tendency to infer health benefits as highlighted in our findings 70 in this study sugar consumption included was related to availability social influences limited parental nutrition knowledge flavour enhancement and convenience of sugary foods and drinks it is well understood that dietary factors specifically sugar consumption increase the availability of fermentable carbohydrates required for acid formation and ecc development while simultaneously increasing host susceptibility due to the influence of prenatal and infant nutrition on enamel development 5671 the misconception that baby teeth are less important than permanent dentition was cited as rationale for exposing children to sugar this perception has previously been identified as a barrier to preventive care in young indigenous children 50 many parents in our project talked about the availability of sugar as a barrier to decision making because its everywhere similarly indigenous mothers from queensland identified lower sugar exposure during their own childhood when compared to their children because processed foods were not as common 50 the transition from traditional diets to western diets due to processes of colonisation and a loss of traditional foods has been explored and identified as a contributing factor to a variety of health inequities experienced by indigenous peoples globally 7 sugar consumption is influenced by many factors within the home school and wider community environments 1872 even when parents are attempting to limit consumption they cannot control what happens in schools or with other family members beyond an increase in knowledge healthy food choices need to be possible within a given environment and when education efforts do not consider environmental influence they are ineffective at initiating behaviour change 73 the subgroup comparison provided insight into how different socioeconomic positions influence barriers to establishing oral health practices for indigenous children lower socioeconomic status is directly related to oral health disparities in australia 68 and indeed globally 74 one of the largest trends was that families living in nonmetropolitan areas were more likely to identify barriers across all subgroups than those living in metropolitan areas this finding highlights the need for holistic targeted dental public health efforts in rural and remote communities across south australia parent employment status children in care and maternal age impacted frequency of barrier identification in various ways the subgroup comparison highlights barriers for families of different demographics and has the potential to inform future policy research and interventions for specific subsets of the population strengths and limitations this paper adds to the limited qualitative research on indigenous oral health in australia and highlights indigenous voices that illustrate the challenges carers face in optimising oral health for their children within westernised environments the structural barriers identified by parents are part of a system that has historically excluded indigenous voices despite their direct impact on indigenous health 75 a strength of this project is the use of mi as the conversational methodology respected through indigenous traditions of yarning and provided the space and time for participants to engage in conversations 30 the variation in prominence of themes is representative of participants experiences due to the structure of mi where the interviewer is positioned as a knowledgeable person accessible for participants to engage with on topics rather than prioritising topics and questions with a structured guide additionally this project is unique in that socioeconomic positions were compared to identify how barriers exist for families in different situations a limitation of the study is that baseline measures for age and employment used for subgroup comparisons reflect maternal characteristics rather than the entire household additionally the majority of interviews were conducted with mothers at baseline occurred during pregnancy however future projects would be more impactful by prioritising paternal participation and engaging the whole family as aligned with cultural understandings of holistic health conclusion despite the barriers shared by participants and discussed here parents understood the importance of oral health and desired the best possible outcome for their childrens teeth policymakers researchers and public health professionals are urged to consider the barriers experienced firsthand by indigenous peoples and prioritise indigenous partnerships when addressing oral health disparities our recommendations from these findings include an increased focus on oral health promotion efforts in nonmetropolitan areas the utilisation of community experiences and needs in creating useful strategies that encourage oral health and nutrition knowledge and the extension of oral health initiatives and future research to include all family members abbreviations ecc early childhood caries ft fulltime metro metropolitan nonmetro nonmetropolitan mi motivational interviewing pt parttime ue unemployed 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 during the 1970s optimal oral health was experienced more frequently amongst indigenous children in australia than their nonindigenous counterparts as a result of public health interventions targeting oral disease oral health has improved for most children however indigenous children today experience oral disease at alarmingly high rates a history of colonisation assimilation racism and cultural annihilation has had profound impacts on oral health for indigenous peoples compounded by environmental dispossession and a shift from traditional diets to one of processed and nutrientpoor foods often high in sugar methods this project aimed to identify factors related to the increased occurrence of caries in indigenous children using purposive sampling from the larger project this paper thematically analyses 327 motivational interviews to explore current barriers impeding parental efforts to establish oral health and nutrition practices for indigenous children representation of socioeconomic positions of families were compared across themes as based on maternal age employment residency and number of children in carefindings resulted in a conceptual model of barriers that exist across knowledge social structural and parental factors major thematic results include social consumption of processed foods busy households misleading nutrition marketing sugar cravings and lack of oral health and nutrition knowledgea discussion of the findings results in the following recommendations increased oral health promotion efforts in nonmetropolitan areas utilisation of community experiences in creating strategies that encourage oral health and nutrition knowledge and the extension of oral health initiatives and future research to include all family members trial registration australian new zealand clinical trial registry actrn12611000111976 registered 01022011

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background health insurance has been recognized globally as one of the principal methods of financing healthcare to achieve universal coverage particularly in low and middle income countries many low and middle income countries are currently exploring mechanisms of extending their health insurance schemes to specific groups to eventually cover their entire populations 12 the 2005 world health assembly resolution wha 5833 urged members states to ensure financial protection to all citizens especially children and women of reproductive age and to plan the transition to universal coverage of their citizens 2 given the high demand for healthcare services of appreciable quality and the extreme underutilization of health services in several subsaharan african countries due to financial barriers health insurance has been recommended as a promising alternative to other criticized financing systems like costrecovery and user fees 2 the expectation is that health insurance will improve access to quality healthcare through risk pooling of unforeseeable healthcare cost to fixed premiums 3 in response to this call for developing countries to adopt healthcare financing mechanisms that remove financial accessibility barriers and strive towards the attainment of universal health coverage ghana implemented the national health insurance scheme in 2004 to replace the cash and carry system when patients have to pay outofpocket cash before receiving healthcare the nhis was established through an act of parliament act 650 in 2003 as part of efforts to make the health goal within the ghana poverty reduction strategy achievable and also to accomplish the targets set in the health sector fiveyear programme of work 2002work 2006 46 46 the vision of the nhis was to ensure equitable access to acceptable quality package of essential healthcare to all residents of ghana 4 act 650 was revised in 2012 and replaced with act 852 to remove administrative bottlenecks introduce transparency and reduce opportunities for corruption and gaming of the nhis system 7 the scheme is financed mainly from the national health insurance fund cash inflow into the nhif is from 25 of the 175 value added tax 25 of the 175 social security and national insurance contributions made by formal sector employees member contributions from premium payments and monies that accrue to the fund from investments made by the nhia council the government of ghana also allocated funds to the nhif through parliament and other donor funds 4 5 6 membership of the nhis involves payment of registration fee and insurance premium before an nhis identity card is issued formal sector employees are exempted from payment of premium and therefore have to pay only the registration fee to enroll informal sector workers have to pay the annual premium and registration fee enrolment and financial contribution to the nhis is legally mandatory by act 852 but in practice it is voluntary as there are no penalties for nonenrolment 7 what actually pertains is that the mandatory enrolment and contribution only applies to formal sector employees who pay social security and national insurance trust contributions informal sector workers who form the majority of the ghanaian population have to voluntarily pay the registration fees and premium to enroll in the nhis after more than a decade of implementation the nhis has made significant progress in extending health insurance to the people of ghana the active membership of the scheme increased from 13 million in 2005 to 1015 million in 2013 representing 38 of the ghanaian population 8 there are however wide variations in enrolment coverage between the 10 regions with different rural and urban populations 89 the implementation of the nhis also saw a steady increase in outpatient utilization of healthcare services outpatients utilization increased from under 5 million in 2005 to approximately 24 million in 2012 9 ghana is considered as a rural country with approximately of the population living in rural areas with limited socioeconomic opportunities 10 significant inequalities persist between the rural and urban areas in terms of availability of basic amenities and infrastructure such as water sanitation and health facilities 1011 in 2009 only about 10 of the urban population in ghana lack access to portable water as compared to 26 of the rural population whilst 18 of urban population had access to improved sanitation only 7 of the rural population had improved sanitation 11 large income inequalities also exist between rural and urban populations in ghana the overall poverty rate per capita is 39 for rural areas and 10 for urban areas the rural areas also have severe poverty rate per capita of 25 as compared to 5 in urban areas 11 low productivity and poorly functioning markets for agricultural products have been cited as the main reason for the poverty gap between urban and rural ghana 11 the nhis was therefore designed as a propoor initiative to ensure financial protection of the vulnerable in society including women and children in rural areas with a graduation premium based on socioeconomic status however in reality premiums are generally flat rated at the district levels due to the general difficulty in classifying subscribers according to their relative socioeconomic status 12 several studies have examined the determinants of health insurance enrolment and identified economic factors sociodemographic factors place of residence behavioral factors and household size as some of the important determinants income employment and wealth index are very important economic determinants of health insurance enrolment cameron et al 13 asenso et al 14 sanhueza and ruiztagle 15 and ying et al 16 examined the relationship between income and health insurance they all concluded that income predicts health insurance purchase economic theory shows that income has a fundamental influence on the decision to purchase health insurance as a normal good thus higher income increases the affordability of health insurance premium because at higher income the opportunity cost of insurance purchase reduces 1718 other studies found that education and employment have direct positive correlation with health insurance enrolment 19 20 21 sociodemographic determinants of enrolment such as age gender education and marital status are often used to explain why some individuals may be employed have high income and in high wealth index but still does not to enroll in health insurance economic theory indicates that as individuals age they experience depreciation in their health stock and tend to purchase health insurance as an investment in health to avoid catastrophic health expenditure in the event of ill health 22 however the empirical evidence on the effect of age on health insurance enrolment has presented inconsistent results while mwaura 23 bhat and jain 24 kronick and gilmer 25 savage and wright 26 and ayitey et al 27 found advanced age to increase the likelihood of health insurance enrolment ying et al 16 jutting 25 and brugiavini and pace 28 found that being young increases the probability of health insurance enrolment other studies also found that higher level of education and being married also increases the likelihood of health insurance enrolment 141623 27 28 29 a study by muurinen 30 however reported a contrary finding that the highly educated are less likely to purchase health insurance and explained that highly educated people are likely to be healthier with low probability of risk hence will have lower likelihood of health insurance enrolment studies by butler 31 and ayitey 14 revealed that people who are employed and those on executive positions have a higher probability of health insurance enrolment the evidence on the effect of gender on health insurance enrolment have reported inconsistent findings while asenso et al 14 and bourne kerrcampbell 29 found that male headed households and being male increases the likelihood of health insurance enrolment ayitey et al 27 jutting 32 and mwaura 23 found that female headed households and females are more likely to enroll in health insurance the literature is however emphatic that married couples are more likely to enroll in health insurance 2733 similarly larger household sizes have been reported to significantly increase the probability of health insurance enrolment 273435 religion has also been reported as a significant predictor of health insurance enrolment 36 again the empirical evidence on the effect of residential locality on health insurance enrolments has been inconsistent while some studies found little or no difference in ruralurban health insurance enrolment 3637 others found residential remoteness to be a significant determinant of health insurance enrolment 38 39 40 41 42 43 44 yet other studies also found urban locality of residence to be a significant determinant of health insurance enrolment 1417 45 46 47 48 49 in terms of effect of health status and frequency of health facility visits on health insurance enrolment the empirical evidence shows that individuals who are ill are more likely to enroll in health insurance and so are those who make more health facility visits 12750 from the evidence available in the literature it can be deduced that the demographic characteristics of the inhabitants and the socioeconomic differences that exist within the rural and urban areas and between the different regions of ghana may be responsible for the observed differences in health insurance enrolment in the regions although several studies have been conducted to identify the determinants of health insurance enrolment in ghana 121420212728343644 to the best of my knowledge no study has specifically examined the differences in these determinants between rural and urban communities and between the different regions of the country this paper seeks to contribute to the broader understanding of determinants of health insurance enrolment in resource constraint setting the paper compares the determinants of enrolment in two regions that are geographically similar but socioeconomically different the paper specifically assesses the differences in determinants of nhis enrolment between the two regions for the total samples the urban sample and finally the rural sample this study will be relevant to policy makers as it will deepen their understanding of the factors that influence the decision to enroll in the nhis differently in the different regions this knowledge is expected to help policy makers decide on the best strategies to adopt to increase health insurance enrolment in the current era of nhis reforms methods study settings this study uses data from the clientoriented health insurance system in ghana project baseline survey that was conducted in the greater accra and western regions of ghana in april 2012 these two coastal regions have similarities and differences as far as rural and urban populations and socioeconomic activities are concerned table 1 presents the differences and similarities between the greater accra and western regions these two regions were purposively selected to provide ruralurban as well as socioeconomic differences that are of interest to the study and allow the assessment of its impact on health insurance enrolment data source this study uses primary data from the baseline survey of coheision project data was collected from 1920 randomly selected households within 10 km radius of selected primary healthcare facilities in the two regions respondents were sampled through a multistage sampling strategy first 16 districts with the same or almost same characteristics such as total population nhis enrolment coverage total number of accredited health centresclinics and urban or rural categorization were selected for the project sixtyfour clusters of nhis accredited primary healthcare facilities were then selected from the selected districts on the basis of their ownership location and nhis accreditation quality scores subsequently 30 households were randomly sampled from within a 10 km radius of each selected primary healthcare facility this sampling process ensured that a selected facility is the only primary healthcare facility within the 10 km radius catchment area it also satisfied the randomized controlled trial design of the coheision project that required equal number of intervention and control health facilities respondents were contacted for the interview in april 2012 a semistructured questionnaire was used to collect information on respondents sociodemographics social capital and social schemas employment status health status and healthcare utilization behavior nhis enrolment status consumption expenditure patterns and dwelling characteristics in total data on 7097 household members was generated from the survey this paper analysis data on 4214 individuals who were 18 years and above theoretical framework the expected utility theory of demand for insurance under conditions of uncertainty and risk aversion by von neuman and morgenstern contends that health insurance enrolment decision is one of a discrete choice to enroll or not 51 the theory assumes that individuals are risk averse and make choices between taking risk with different implications on wealth thus at the time of health insurance enrolment decision individuals are uncertain about whether they will be ill or not and also of the financial implications should they become ill individuals enroll in health insurance to protect themselves from catastrophic health expenditures in the event of ill health the expectation is that in the event of ill health the cost of treatment will be covered by the health insurance and in most instances this cost is more than the health insurance premium paid representing a gain the decision to enroll is therefore arrived at by comparing the expected utility with health insurance to expected utility without health insurance risk averse individuals prefer to pay a certain known amount as health insurance premium to uncertain amounts of the same expected utility in the event of ill health 52 53 54 according to the expected utility theory the demand for health insurance by risk averse individuals to avoid the risk of wealth loss should be higher than risk neutral individuals who are indifferent about health insurance enrolment and risk loving individuals who would not want to purchase health insurance 5556 this paper will rely on the expected utility theory to understand the determinants of enrolment in the nhis in ghana empirical model the focus of this study is to interpret the dependent variable as a likelihood of enrolling in health insurance or not given other explanatory variables the logit model is employed in the empirical estimation this is because the logit model is able to overcome the problems associated with the linear probability model which allow the use of ordinary least square to estimate the parameters the lpm is plagued with heteroscedasticity nonnormality of the disturbance term low r 2 and nonfulfilment of the 0 ≤ ≤ 1 restriction of binary models the logit model has the advantages of being more robust such that the independent variables dont have to be normally distributed or have equal variance in each group does not assume a linear relationship between the independent and dependent variables does not assume homogeneity of variance and does not assume normality of error term the maximum likelihood method is used to estimate the parameters 27 the functional model for the determinants of health insurance enrolment can be formulated as follows h ã ¼ f d l π 2 i ð þ ð1þ where source 2011 nhia annual report 9 2010 population and housing census 10 and gender inequalities in rural employment in ghana an overview 11 i individuals income h nhis when the logit model is applied to eq it can be expressed as logit h ã ð þ ¼ β 0 þ x k i j¼1 β j x i þ ε ijð2þ the assumption with the logit mode is that there is a continuous latent variable y that determines enrolment in the nhis thus if y is positive then the individual will enrol in the nhis and the observed binary outcome is one otherwise the outcome is zero the latent variable y is therefore modelled by a linear regression function of the individual 27 the estimable equation is therefore formulated as nhisstatus ¼ β 0 þ β 1 female þ β 2 age i þ β 3 nevermarried þβ 4 otherreligion þ β 5 hhsize þβ 6 noformaledu þ β 7 unemployed þβ 8 poorhealthstatus i þ β 9 poorestwealth þβ 10 disttofacility þ β 11 public measurement of variables current enrolment in the nhis is defined as the dependent variable of interest for this study it assumes a value of 1 if the individual is currently enrolled in the scheme otherwise 0 the ghana statistical service 2010 population and housing census classification of rural and urban areas was used to classify individuals as living in either rural or urban area 4 according to this classification five out of the eight selected districts in the greater accra region are urban districts and the remaining three are rural districts it also classified five out of the eight selected districts in the western region as rural and three as urban districts other demographic socioeconomic health status characteristics of respondents and characteristics of the health facilities that empirical evidence suggest can influence health insurance enrolment were included in the estimation as explanatory variables the explanatory variables included in the estimation are age gender religion marital status household size educational level employment status wealth status health status private public health facility and time taken to move from home to the nearest health facility table 2 summarizes the dependent and independent variables used in the analysis and how they were measured data analysis in analyzing the data 4214 individuals for the age cohort of 18 years and above was used first descriptive statistics was used to present respondents proportionaverage demographic and socioeconomic characteristics in the two regions for the total urban and rural samples bivariate analysis was performed to examine differences in respondents characteristics between the two regions for the total urban and rural samples finally logistic regression estimation was performed to identify the determinants of enrolment in the two regions for the total urban and rural sample respondents who were enrolled in insurance schemes other than the nhis were excluded from the regression estimation results characteristics of respondents table 3 present respondents demographic socioeconomic and health status characteristics by rural and urban areas in the total gar and wr samples the average age in the total sample is 38 years the average age in the gar is slightly higher than their wr counterparts urban adults in the gar are older than urban adults in the wr similarly rural adults in the gar are older than rural adults in the wr there are more females in the total sample than males similarly there are more females in the gar and wr respectively than males there are more married respondents in the total sample the gar and wr respectively than the other categories of marital status there are however more married couples in both urban and rural gar than in urban and rural wr majority of respondents in the total sample gar and wr are christians there are however slightly more christians in urban wr than urban gar whiles rural gar has more christians than rural wr there are approximately 5 members per household in the total sample 4 members in gar and 5 members in wr respectively urban gar and urban wr have the same household size of 4 members similarly the average household size in rural gar is equal to average household size in rural wr more than half of respondents in the total sample gar and wr have completed basic level of education the proportion of adults with basic level of education in urban gar is less than their urban wr counterparts majority of respondents in the total sample gar and wr are gainfully employed those employed in urban wr are more than those in urban gar however both rural gar and rural wr have equal proportion of 72 employed adults almost all of the employed adults in the total sample gar and wr are in fulltime employment of those employed 47 in total 52 in gar and 42 in wr samples are artisanstraders there are more tradersartisans in urban gar than urban wr similarly there are more artisanstraders in rural gar than rural wr the richest wealth quintile had the highest proportion of 24 of respondents in the total sample and 30 in gar than other wealth quintile however in the wr the highest proportion of 23 of respondents are in the poorest wealth quintile the proportion of respondents in the poorest wealth quintile in urban gar is far smaller than their urban wr counterparts conversely the proportion of respondents in the richest wealth quintile in rural gar is much higher than their rural wr counterparts majority of respondents in the total sample gar and wr indicated that they are of good health the average annual income from all sources for respondents in the total sample is gh 234076 gar and wr whilst average annual income level in urban wr is higher than urban gar average annual income in rural gar is higher than their rural wr counterparts the proportion of urban respondents in wr with good health status is more than their urban gar counterparts conversely the proportion of respondents in rural gar with good health status is more than their rural wr counterparts most of health facilities in the total sample gar and wr were public owned facilities whiles urban gar has more private than public health facilities urban wr has approximately equal private and public health facilities on the average it takes approximately 12 min to move from home to the nearest health facility in the total sample 13 min in gar and 14 min in the wr it takes less time to get to the health facility in urban gar than urban wr however it takes more time to get to the health facility in rural gar than in rural wr regional differences in characteristics by rural and urban samples table 4 presents the bivariate analysis of health insurance enrolment and other explanatory variables between the two regions for the total urban and rural samples the wr have a higher health insurance coverage than the gar in the total sample health insurance coverage in the urban sample is higher for gar than the wr however in the rural sample health insurance coverage is higher in the wr than the gar these differences in insurance coverages are statistically significant at the 90 confidence interval in terms of type of health insurance the wr again have a higher nhis coverage than the gar in the total sample for the urban sample the gar have a higher nhis coverage than the wr whiles in the rural sample the wr have a significantly higher nhis coverage than the gar the average age of respondents in the gar is significantly higher than the wr in the total sample there is however no statistically significant difference in the average age of respondents in the urban or rural samples similarly there is no statistically significant difference in the proportion of females and males in either the total urban or rural samples although in the total sample there are more married respondents in the gar than the wr the differences in the proportion of married respondents between the regions in the urban and rural samples are statistically insignificant as shown in table 4 the proportion of respondents with basic level education is significantly higher in the gar than the wr in the total sample similarly in the urban sample the proportion of respondents with basic level education is higher in the gar than the wr there is however no statistically significantly difference in the proportion of respondents with basic level education between the gar and wr in the rural sample in terms of health status there is no statistically significant difference in the categories of health status between the gar and wr for the total and rural samples the gar however have higher proportions the health status categories than the wr in the urban sample the proportion of respondents in the richest wealth quintile is significantly higher in the gar than the wr in the total sample similarly the proportion of respondents in the richest wealth quintile is significantly higher in the gar than the wr however there is no statistically significant difference in wealth status categories between the gar and wr in the rural sample there is also no statistically significant differences between the gar and wr in terms of religion employment health facility ownership and average time to health facility either for the total urban or rural samples determinant of health insurance enrolment table 5 presents the logistic regression estimations of the determinant of nhis enrolment among workingage adults for the total urban and rural samples estimating individuals income in developing countries is difficult and unreliable because most people are reluctant to disclose their true income a five quintile wealth status was therefore computed from household food and nonfood consumption expenditure as a proxy for income levels and used in the regression estimation again due to the inability of respondents to accurately determine the distance in kilometers from their home to the nearest primary healthcare facility time taken in minutes to move from home to the nearest primary healthcare facility was used as a proxy to measure distance from home to health facility the differences in the determinants of enrolment between the two regions are presented the results show that generally age sex marital status educational level health status wealth status and health facility ownership are significant determinants of nhis enrolment at varying extents between the gar and the wr for the total urban and rural samples for the total sample females are significantly more likely to enroll in the nhis than males for both the gar and wr similarly for both the urban and rural samples females are significantly more likely to enroll in the nhis than males in the gar and wr these findings are consistent with findings by mwaura 23 ayitey et al 27 and jutting et al 32 age also impacts positively on nhis enrolments the results show that an increase of 1 year in age significantly increases the odds of nhis enrolment in both regions for the total rural and urban samples these findings are consistent with findings by bhat and jain 24 kronick and gilmer 25 savage and wright 26 and ayitey et al 27 in terms of marital status for the total sample whiles divorcees are 108 times more likely to enroll in the nhis in the gar their wr counterparts are 066 times significantly less likely to enroll for the urban sample although divorcees in both regions are less likely to enroll as compared to those married the results for the wr is statistically significant at the 95 confidence interval however for the rural sample whiles divorcees in the gar are 122 more likely to enroll their wr counterparts are 073 less likely to enroll even though this result is statistically insignificant at the 90 confidence interval this finding is in contrast with earlier studies by asenso okyere et al 14 ayitey et al 27 and brugiavini and pace 28 who found married individuals to be significantly more likely to enroll in health insurance although the results further shows that being married increases the odds of nhis enrolment in both regions for the total urban and rural samples these findings are statistically insignificant at the 90 confidence interval similarly although the results show that being a christian and a 1 member increase in household sizes increases the odds of nhis enrolment these findings are statistically insignificant even at the 90 confidence interval the results also show that an individuals level of education influence the odds of nhis enrolment for the total sample having secondary level education and above significantly increases the likelihood of nhis enrolment by 149 times in the gar and 162 times in the wr respectively as compared to individuals with no formal education for the urban sample although the results shows that secondary level education and above increases the odds of enrolment by 137 times in the gar and 195 times in the wr these findings are statistically insignificant at the 90 confidence interval however for the rural sample individuals with secondary level education and above are significantly more likely to enroll in the nhis by 207 times in the gar and 167 times in the wr these findings are consistent with findings by asenso okyere et al 14 ayitey et al 27 and brugiavini and pace 28 the results show being employed does not positively influence nhis enrolment in both regions for the total urban or the rural samples these findings are however statistically insignificant at the 90 confidence interval although the finding was statistically insignificant individuals with poor selfassessed health status are more likely to enroll in the nhis than those with fair or good health status in both regions for the total urban and rural samples ayitey et al 27 reported similar findings of the effect of selfassessed health status on nhis enrollment the results show that wealth status is a significant determinant of nhis enrolment at varying extent in the two regions depending on the ruralurban locality of residence of the individual for the total sample the richest in the gar are 173 times more likely to enroll in the nhis than the poorest whiles in the wr the rich and the richest are 177 times and 204 times respectively more likely to enroll in the nhis than the poorest however when the urban and rural samples are considered separately whiles in the rural sample individuals in the richest wealth quintile in the gar are 255 times and wr are 176 times significantly more likely than those in the poorest quintile in the urban sample individuals in the richest wealth quintile in both regions are more likely to enroll these finding are statistically insignificant at the 90 confidence interval these findings are in agreement with findings by ayitey et al 27 and fowler et al 50 in terms of travel time from home to the nearest primary healthcare facility although a 1 min increase in the travel time reduces the odds of nhis enrolment of individuals in the wr for the total urban and rural samples these findings were statistically insignificant at the 90 confidence interval from the results ownership of the nearest primary healthcare facilities is another significant determinant of nhis enrolment individuals who live around the catchment area of a publicly owned primary health facility in the gar are 183 times and 178 times significantly more likely to enroll in the nhis for the total and urban samples respectively however in the rural sample individuals who live in the catchment area of private facilities are significantly more likely to enroll in the nhis than those who live around public facilities discussion the study assessed the differences in determinants of nhis enrolment among workingaged adults in the gar and wr in ghana the findings indicates that age sex educational level marital status health status wealth status and health facility ownership are significant determinants of nhis enrolment females in both regions are more likely to enroll compared to males similarly urban and rural females in both regions are more likely to enroll in the nhis than males this may be as a result of the free maternal health policy under the nhis which offer premium exemption to expectant and nursing mothers and therefore most females in the reproductive agegroup might have enrolled under this exemptions category the likelihood of nhis enrolment was also found to increase with age for both regions in the total sample and similarly for both regions in the urban and rural areas this positive relationship of increasing age with nhis enrolment can be attributed to degeneration in health as people age and the need for increased healthcare utilization older people therefore prefer to make investment in their health through the purchase of health insurance this findings is consistent with the findings of previous studies 202736 the increased likelihood of the aged to health insurance enrolment can also be attributed to the exemptions of people aged 70 years and above from premium payment under the nhis exemption policy most of the aged therefore enrolled under the 70 age exemption category married people are more likely to enroll in the nhis in both regions for the total sample and similarly in both regions in the urban and rural areas than never married people this may be because married couples purchase health insurance to mitigate the financial burden that is likely to accrue from raising children after marriage 273133 the findings also point to educational class dimensions in nhis enrolment the better educated in both regions in the total and rural sample are significantly more likely to enroll than the uneducated although the results from the urban sample is statistically insignificance there is still a positive relationship between higher education and nhis enrolment in both regions this positive relationship between higher education and nhis is because higher education makes people better understand and appreciate the insurance concept and its benefits to the household people with poor selfassessed health status in both regions are more likely to enroll in the nhis in the total and urban samples than those with fair and good health status however in the rural sample people who are of fair health status in the gar are more likely to enroll in the nhis than their wr counterparts this suggest that people who are of poor health in urban communities on both regions selfselect into the nhis perhaps the availability of both public and private health facilities in urban communities is such that people of poor health get to know of their underlying propensity to increased healthcare utilization they therefore enroll in the nhis to protect themselves from catastrophic healthcare expenditure theoretical concepts such as adverse selection risk aversion affordability and trust which are beyond the scope of this study can help explain and put these findings into proper perspective workingage adults in the rich and richest quintiles in both regions in the total sample are significantly more likely to enroll in the nhis than those in the poorest wealth quintile this suggest that wealth status and therefore affordability of insurance premium is an important determinant of nhis enrolment in the urban sample the odds of nhis enrolment for wr individuals in the rich and richest quintiles is about twice that of those in the gar conversely in the rural sample the odds of nhis enrolment for gar individuals in the richest quintile are about twice that of those in the wr thus the rich in urban wr enroll more in the nhis than the rich in urban areas in the gar however in the rural areas the rich in rural gar enroll more in the nhis than the rich in rural wr the expectation is that with the propoor design of the nhis and its extensive exemption policy that exempt premium payment for indigents the poor in rural areas in both regions will enroll more than the rich these finding further galvanize findings by earlier studies that poverty is a major barrier to nhis enrolment and that the nhis is not propoor as envisaged 27 the fact that the odds of enrolment among the rural rich in the gar is higher than rural rich in wr further indicates that levels economic activities income levels and affordability of premium in the rural areas also impact on the decision to enroll in the nhis although the wr has a high poverty rate of 18 compared to the gar 12 the nhis enrolment rate in the wr is higher than the gar however the likelihood of enrolment is significantly higher among the richest in the wr than in the gar this can be explained from the fact that the richest in the wr do not have access to many private health facility and private health insurance companies like the richest in the gar so even if the richest in wr are not satisfied with the quality of care from public health facilities which they will attend should they enroll in the nhis they will still have to attend these same public facilities should they opt out of the nhis and pay outofpocket or enroll with other private health insurance unlike the gar where the richest have access to many private insurance companies and private healthcare facilities the richest who decide to opt out of the nhis for quality issues have readily available alternatives travel time from home to health facility is another important determinant of nhis enrolment between the regions the average travel time to the nearest health facility is higher in the wr than the gar for the total urban and rural samples it is therefore not surprising that a 1 min increase in the travel time in the wr reduces the odds of nhis enrolment for the total urban and rural samples the ownership of the nearest primary health facility is another important determinant of nhis enrolment people who visit public health facilities in the gar are more likely to enroll in the nhis than their wr counterparts for the total and urban samples however in the rural areas this is not the case as those who visit private facilities are significantly more likely to enroll in the nhis in both regions a possible explanation to this could be about perceived poor quality care from these public facilities which may influence peoples decision to enroll in the nhis this is because per the nhis gate keeping system card holders are expected to first visit a primary health facility when sick if people perceive the quality of care they receive from their nearest primary health facility to be poor chances are that it will discourage them from enrolling in the nhis conclusion the study assessed the differences in determinants of nhis enrolment among workingaged adults in the gar and wr in ghana the analysis employed logistic regression in the empirical estimation the study did not find any differences in the demographic determinants of nhis enrolment between the two regions and among the rural and urban residents in the two regions the findings indicate that generally age sex educational level marital status health status and travel time to health facility are significant determinants of nhis enrolment in both regions and similarly in the rural and urban communities in the two regions the study however found some differences between the two regions in terms of wealth status and health facility ownership as determinants of nhis enrolment although the rich and richest in both regions are more likely to enroll in the nhis than the poor and poorest the odds of nhis enrolment for the richest in urban areas in the wr is about twice as that of gar whiles in the rural areas the odds of nhis enrolment in the gar is also about twice that of the wr people who visit public health facilities in the gar are more likely to enroll in the nhis than those in wr for the total and urban samples however in the rural areas those who visit private facilities are significantly more likely to enroll in the nhis in both regions these findings suggest that inequalities still exists in nhis enrolment in favor of the wealthy communities with better socioeconomic activities and communities with health facilities that are perceived to provide better quality healthcare this thus raises concerns as to whether the nhis is truly propoor as envisaged the study contributes to the literature on the determinants of nhis enrolment by identifying factors that might be responsible for the observed differences in the nhis regional enrolment coverages the differences in nhis enrolment coverages between the regions may be as a result of differences in socioeconomic factors that impact on the ability of the inhabitants to afford the insurance premium this should serve as an important indicator to policymakers on the need to focus on regional specific geographic and proxy means targeting strategies aimed at identifying the poor in resource constraints communities for premium exemptions the study recommends that policymakers should use innovative approaches to determine nhis premium at the district level based on socioeconomic activities and income levels within the district they should also consider introducing quality healthcare dimension into provider payment mechanisms to rewards providers who meet quality criteria as expressed by their clients this will serve as an incentive for both public and private accredited healthcare providers to provide quality healthcare that attract individuals to enroll in the nhis finally the findings of this study is subject to the following limitations the analysis relied on selfreported measures such as health insurance enrolment status patterns of enrolment and selfassessed health status therefore any systematic differences due to respondents reporting bias could affect the precision of the reported estimates the study did not include individuals insured with other private insurance companies other than the nhis due to the small sample size in the data these limitation however does not invalidate the entirety of the selfreported measures and the analysis of these measure which have been welldocumented the findings of the determinants of nhis enrolment reported in this study are limited to the greater accra and western regions of ghana and therefore caution should be taken when generalizing the findings to other populations abbreviations coheision project clientoriented health insurance system in ghana project gar greater accra region gss ghana statistical service nhia national health insurance authority nhif national health insurance fund nhis national health insurance scheme now netherlands organization for scientific research ssnit social security and national insurance trust wha world health assembly wotro science for global development wr western region authors contributions skod initiated the conceptualization collected the data conducted data analysis and prepared the manuscript the author read and approved the final manuscript competing interests the author declares he has no competing interests

background ghanas national health insurance scheme nhis has achieved varying levels of enrolment within the regions with different ruralurban populations with associated income inequalities this study sought to investigate the differences in the determinants of enrolment between the greater accra gar and western wr regions of ghana to inform the nhis reforms method data from 4214 adults 18 years and above from a household survey conducted in the two regions was analyzed bivariate analysis ttest for continuous and pearson chisquare for categorical was performed to examine differences in respondents characteristics socioeconomic and insurance enrolment between the two regions for the total urban and rural samples logistic regression estimation was performed to establish differences in determinant of enrolment between the regions results age sex educational level marital status health status and travel time to nearest health facility were identified as determinants of enrolment in both regions and among the rural and urban residents within the regions although the rich and richest in both regions are more likely to enroll than the poor and poorest the odds of enrolment for the urban richest in the wr is about twice that of gar whiles the odds of enrolment for the rural richest in the gar is also about twice that of the wr those who visit public facilities in the gar are more likely to enroll than those in wr for the total and urban samples however those who visit private facilities in rural communities in both regions are more likely to enrolldifferences in the nhis enrolment between the regions is as a result of differences in socioeconomic factors that are intrinsic in the regions and impact on the inhabitants ability to afford insurance premium policymakers should determine nhis premium differently at the district level based on socioeconomic activities and income levels within the districts

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introduction with growing recognition of the potential severity of human induced climate change interest in how local communities and diverse actors can become more resilient in the face of climate related shocks and stressors is rapidly growing this growing interest on resilience1 buildingbroadly defined as the ability of placebased or interest based communities to proactively cohere and develop abilities to be able to adapt in the face of different kinds of shocks and stressors has occurred alongside a rapidly growing body of research from diverse disciplines on resilience more generally and in relation to a diversity of contexts and fields of study through such work a plethora of different factors that enhance or constrain resilience at community levels and other social levels2 have been identified such work highlights for example how enhancing community resilience requires approaches well beyond just technical or infrastructural interventions to including consideration of diverse social and psychological factors for example in the field of emergency management quality infrastructure is an important factor to access vital services in other fields such as rural development and urban studies diverse incomes and institutions that mediate interests and access to resources and opportunities are important in shaping abilities to overcome shocks and to adapt to longterm stresses a core subset of such research related to community resilience building and often resilience more generally has broadly focused on the role of different social factors that shape potential or actual collective action for change and resilience such work has highlighted for example the importance of local knowledge sharing clear communication social learning and peopleplace connections which shape perceptions and actions in relation to increased risk of extreme weather events or the importance of safety nets and factors such as confidence and aspirations for overcoming threats to food security many of these studies referring to different social factors use the lens of social capital this conceptual lens focuses attention on the social relationships networks and trust in shaping outcomes such as in mobilising collective action within and between different social groups for disaster management in general to respond to a range of shocks and in terms of specific threats such as wildfires also social capital to promote and coordinate collective actions in communities to adapt to climate change and informally within organisations and for supporting community innovation for renewable energy initiatives for climate mitigation the literature on social capital andor resilience is now vast and drawing out its implications for informing community resilience building conceptually and in practice is a significant challenge while there have been past reviews two important knowledge gaps remain first there has been limited focus on the practical insights emerging from studies of social capital and community resilience building for actionorientated knowledge on how to better navigate and work with the multiple factors to actively enhance resilience across community settings with many reviews instead usually focusing on higher level conceptual foundations second reviews have also tended to underplay the issue that the way both resilience and social capital are framed together has significant implications for the research being conducted and any conclusions being drawn from them this has limited the possibility for more nuanced understandings of both the broader conceptual and practical insights and identification of the critical knowledge gaps that need to be addressed in future research this paper therefore aims to review research on the role of social capital in supporting resilience building to identify practical implications and knowledge gaps broadly within the context of climate change we first provide a brief overview of both social capital and resilience and explain how the review was approached we then present our findings on how social capital andor resilience is being conceptualised and the empirical findings about how social capital can shape resilience finally critical research gaps are identified to better understand how to apply social capital approaches to promote community resilience in relation to climate change resilience social capital and climate change this review seeks to understand the role of social capital in supporting community resilience building community resilience is has been defined as the existence development and engagement of community resources by community members to thrive in an environment characterised by change uncertainty unpredictability and surprise or resilience as a process linking a set of adaptive capacities to a positive trajectory of functioning and adaptation emphasis has also been placed on the way human social aspects are closely intertwined with ecological dimensions and dynamics with much of what happens at community levels being influenced by interactions at multiple levels and scales importantly and as highlighted by ross and berkes much of the understanding of resilience requires finding ways to combine different factors and influences to inform how community resilience building may be advanced recognising that it is ultimately a process rather than necessarily an end goal that involves developing different forms of adaptive capacity and agency community resilience is thus often closely linked to different aspects of economic development and requires attention to normative aspects and being driven by values and human agency that shape goals and how social action unfolds for example to enhance control of land by communities land first needs to be collectively recognised as important policy environments also need to shift to enhance community control in principle and different capacities and resources need to be actively brought together to bring this about in practice a community perspective emphasises community actors developing and engaging resources for the community to thrive in the face of change such change for example can be more specific and while being unanticipated easily identifiable such as fires or floods other change may be more diverse or unanticipated different kinds of resiliencegeneralised or specificthen require different approaches to resilience building in the context of challenges such as climate change a narrow focus on specified resilience may hinder more generalised community resilience thus some approaches to building resilience may have limited potential for engaging with the complexities of climate change as such there has been a growing interest in developing integrated systemic approaches to enhance specified and generalised resilience concurrently and to working with issues that may arise over longer time frames and which more effectively integrate normative dimensions such as values social norms and power while there are many different understandings of resilience we broadly take the view that community resilience building requires both focus and holism and thus requires attending to systemic aspects and working with different actors perspectives needs and diverse facets of the climate change challenge like resilience social capital is another contested concept with many different interpretations social capital has been applied in many disciplines from sociology political science economics community and international development the concept has often been applied to highlight opportunities to enhance initiatives or programmes at diverse levelssuch as for enhancing household food security through memberships of farmers organisations and involvement in other community activities at the community level to maximise opportunities to enhance collective social capital within different types of interventions or for largescale regions to ensure social capital is maintained in the immediate aftermath of flooding to strengthen the potential for longterm recovery in studies at community levels social capital is often framed or defined as social relationships or networks and how this provides a utilitarian resource such conceptualisations are broadly structural and focus on connections between actors contentbased approaches emphasising attributes that shape outcomes and approaches that aim to integrate these recognition that diverse types qualities and magnitudes of outcomes emerge from social relationships has involved a shift away from framing social capital as being only positive such as with many examples of social capital reinforcing socioeconomic exclusion and resistance and which has led to an increasing emphasis on the importance of power and norms in shaping what unfolds and for whom from social capital given that much of the emphasis on community resilience is often assumed to come from the way in which individuals and groups are able to organise and that the concept of social capital is often assumed to be a core mechanism underpinning effective individual and collective action it is then not surprising that there have been a large number of studies which in some way have examined the interaction between the two the concept of social capital for example has been widely used to understand interventions aiming to enhance adaptive capacities and resilience this includes those directly related to climate change and the community level such as in relation to natural hazards and more generally at the community level in terms of supporting health outcomes enhancing economic development and increasing participation in collective decisionmaking social capital has also often been viewed conceptually as core for community resilience in summary building community resilience in the context of climate change is an important but complex social process it is inherently linked in diverse ways to social dynamics such as social relationships and networks that are often studied or understood through the lens of social capital while there have been many different studies on the relationships between resilience building and social capital there has been rather limited emphasis on reviews that draw out the implications of social capital for the practice of resilience building more generally this has been hampered by the many different interpretations of both resilience and social capital this review therefore seeks to draw out practical and empirical insights from different studies in a way that considers the different ways in which resilience and social capital have been understood methodology this review was approached as a metasynthesis employing interpretivist and qualitative methods to generate substantive and integrated findings in this process a modified version of more systematic review processes was used first a wide range of peer reviewed articles were identified through search engines identifying papers by searching using both the terms resilience and social capital from titles abstracts or key words this resulted in 262 articles articles were excluded if they appeared in the search multiple times were not published in english or could not be accessed reducing the set to 187 papers qualitative and inductive methods were used for analysis this included descriptive nvivo coding to identify text in the articles relating to conceptualisations of social capital resilience and the role of social capital and empirical findings with care taken to avoid subjective and speculative discussion about the empirical findings codes were developed and applied iteratively across studies to allow for new interpretations and potential codes to emerge through the process codes and their interconnections were then explored using visual mapping techniques to develop themes a modified version of the pattern matching was also used to compare and contrast patterns it is important to note that this review was not exhaustive rather it provides an indicative account of what the literature overall tells us about social capital and resilience building there are thousands of papers on resilience and associated social issues and many of these would broadly relate to the topic many pragmatic judgments were needed to ensure the review was sufficiently focused while also encompassing of a diversity of studies as is the case with many qualitative studies the emphasis was therefore on identifying broad patterns by seeking diversity of different studies and interpretations rather than trying to present a more quantified view of what was present in the literature as a whole finally the included papers did not always relate directly to climate change or to the community level our goal was to bring together more generalised insights about the nature and role of social capital in resilience that could then be applied more broadly to community resilience building within a context of major challenges like climate change results and discussion what ways have resilience social capital and the role of social capital been conceptualised concepts of resilience and social capital around three quarters of studies provided definitions of resilience among these there were three general interpretations of resilience reactive resilience responsive resilience or proactive resilience the vast majority of studies viewed resilience as reactive or responsive with few defining it as proactive reactive resilience concerned actions to cope with the immediate aftermath of a shock with an assumed goal of stability and a timely return to the status quo ie to resume business as usual this conceptualisation often assumed the need for topdown command and control or unsupported actions undertaken by local people in contrast responsive resilience was viewed as learning from shocks to enact adjustments to social environmental or physical components ie to strengthen the existing system to reduce negative consequences from future shocks here resilience was viewed as multifaceted encompassing different actors interests and capacities as part of an ongoing process of change finally proactive resilience involved an ongoing process of foresight experimentation reflection and learning requiring systemic perspectives and multiscalar approaches involving norms identities and values and potential need for radical change this view highlighted the influence of governance arrangements meanings and power dynamics and the importance of redundancy flexibility and proactively working to shape complex nonlinear dynamic and context specific change processes considering the multiple dynamic ways climate change interacts with multiple social levels the climate challenge is not likely to be addressed without such systemoriented change that creates opportunities for alternative ways of thinking and acting enhancing proactive resilience is therefore much more likely to be relevant than resilience types that emphasise maintenance of the status quo despite this very few studies viewed resilience as a proactive process with most conceptualising resilience as either reactive or responsive turning to social capital around three quarters of studies defined this explicitly four broad definitions of social capital were identified as social networks social networks and outcomes social networks trust and norms of reciprocity and social networks and sociocultural dimensions of the studies defining social capital around a third defined social capital as social networks with other definitions each accounting for around one fifth of studies within this two typologies of network connections were often used these were strong weak ties or more frequently bonding bridging linking social capital these differentiated along ideas of homophily or sameness and heterogeneity or difference between people and groups these distinguish bonding social capital and strong ties for interpersonal relationships bridging social capital or weak tie across different social groups andor linking social capital emphasising connection across formal hierarchies which implicitly acknowledges underlying power differentials the first conceptualisation viewed social capital as social networks that connect people eg though membership of formal groups the second included social networks and associated outcomes eg improved health information or civil engagement the third conceptualisation viewed social capital as social networks combined with trust and norms of reciprocity here social networks were characterised as structural dimensions while subjective norms of trust and reciprocity were cognitive andor relational dimensions structural and subjective aspects were often argued to be closely intertwined and mutually reinforcing in shaping outcomes however most studies emphasised the structural connectivity between different types of actor more than subjective aspects the fourth conceptualisation viewed social capital as a dynamic relationship between social networks and sociocultural dimensions together these were considered to shape expectations attitudes actions and outcomes such as willingness to cooperate and experiment proenvironmental actions and more sustainable environmental outcomes here sociocultural dimensions included values identities norms beliefs and traditions that encourage or constrain actors actions and resulting outcomes these sociocultural and structural dimensions of social capital interact dynamically to shape expected and actual access to and control over different resources overall few studies considered subjective sociocultural aspects in detail usually focusing on outcomes for specific social groups at the communitylevel studies tended to focus on trust and reciprocity other sociocultural dimensions were often considered superficially without explanation about connections between multiple sociocultural and structural dimensions some recent studies provide more integrative conceptualisations of social capital by for example emphasising social identities and norms of solidarity however overall the limited acknowledgement of sociocultural dimensions may foster misleading interpretations about the type of outcomes that emerge from different social networks this is relevant for climate change as both mitigation and adaptation are needed across all levels of society thus overlooking the role of underlying sociocultural dimensions may place undue emphasis on structural aspects that could hinder understanding how outcomes may come about to enhance resilience to climate change conceptualisations of the role of social capital in resilience when the two concepts were brought together six different conceptualisations emerged of how social capital was expected to influence or give rise to communitylevel resilience the first conceptualisation related to network quantity here the number of links among agents within social networks was assumed to increase social support information and good will which in turn was viewed as important for enhancing the ability to respond to shocks many of these studies viewed bonding social capital as a key buffer to adversity which needed to be cultivated before shocks and activated when needed such studies suggest social networks develop over time and provide critical collective resources to minimise disruptions from climate related shocks however these generally focused on quantifiable aspects and excluded consideration of more subjective dimensions shaping resilience the second conceptualisation of how social capital leads to resilience was through network diversity here different types of social capital were considered important for moving beyond dealing with an immediate crisis to also identify areas for improvement in such studies bonding social capital was emphasised as important for coping with adverse conditions and shocks within communities bridging social capital was considered necessary for new information ideas and knowledge to help shape learning decisionmaking and cooperation between groups such as between communities and government agencies this conceptualisation often assumes that diverse social networks are important for more effective responses to future climate change impacts however these studies did not usually consider a wide range of factors or their interactions as being important in shaping resilience the third conceptualisation was that social capital in the form of networks trust and reciprocity was important for resiliencebut that other assets capacities or collective resources were also required here a need for active management of a combination of natural physical economic and human factors was emphasised but with limited overall explicit consideration given to how such factors interacted or to the wider cultural dimensions involved thus while this conceptualisation suggests that resilience building is a multifaceted social process studies mostly focused on how these gave rise to responsive resilience these studies provided limited understanding of the less tangible and subjective dimensions relating to social capital and resilience the fourth conceptualisation emphasised the role of formal organisations and how these contribute to responsive forms of resilience while considering social capital as networks trust and reciprocity such studies underscored the importance of laws national policy regulatory frameworks and actors in helping or hindering social capital and resilience linking social capital and the ideas and practices within formal organisations were considered important for shaping collective action and for identifying and making adjustments in communities for building resilience sociocultural dimensions relating to power and access to formal processes were sometimes considered but the central focus remained on behaviours of formal actors rather than on less visible underlying sociocultural factors thus this conceptualisation suggests that the goals and practices of formal actors across levels of governance hold strong influence over effective responses to climate change impacts the fifth conceptualisation involves network structures norms and trust being related to proactive resilience these emphasised the importance of enhancing slowchanging factors that would in the long term shape proactive resilience this viewed changes over long periods of time in natural human cultural and social capital as having important implications for flexibility and adaptability this perspective emphasises that joinedup management focused on slowchanging capitals across social scales is important for overcoming a range of climate challenges as they emerge the final conceptualisation highlighted the significance of sociocultural dimensions of social capital in shaping proactive resilience here the core assumption was that sociocultural dimensions are central to proactive resilience processes these sociocultural dimensions included subjective aspects such as sense of place belonging norms identity and values and considered these as closely entwined with material aspects for example resilience could be proactively developed by overcoming collective norms that exclude or favour certain types of actions or that promote a willingness to change this conceptualisation also assumed there are dynamic interconnections between multiple actors identities and goals and explicitly emphasised an important role for power and agency in shaping resilience from this perspective sociocultural factors are important in shaping which aspects of climate change are recognised in decisionmaking and prioritised for action which actors are involved and who benefits overall these conceptualisations show the diverse ways in which social capital is considered to give rise to or enhance resilience with some ways of thinking more prevalent than more nuanced understandings this diversity is derived from the different ways in which social capital and resilience are defined reflecting different underlying epistemologies for example a focus on purely structural dimensions of social capital and on resilience to specific climate shocks tended to reflect positivist perspectives these promote a focus on finding ways to enhance resilience to immediate shocks with less attention paid to deeper social aspects which affect disadvantage and resilience but operate over longer timeframes in contrast conceptualisations that emphasised how diverse sociocultural factors related to social capital were more likely to view resilience as proactive these reflect interpretivist perspectives and place greater emphasis on the deeper underlying causes of challenges that emerge for communities these differences are important as they greatly influenced the kinds of approaches and practice that might be adopted to enhance resilience for example a focus on network quantity and diversity with emphasis on reactive resilience leans towards actions that focus on climate impacts and seek to help a community return to normal rather than responding to climate change in a way that explores deeper causes thus the epistemological and ontological foundations of different understandings of the role of social capital for resilience matter for research and practice being more explicit about such assumptions could help identify the need for broader perspectives to advance understandings eg about how different connections and outcomes unfold across settings and for different types of resilience how does social capital contribute to resilience this section turns to empirical insights from different studies about how social capital shapes resilience and identifies implications for practice these findings are organised around three overarching themes of the role of social capital in influencing resilience factors that interact with social capital to influence resilience and the influence of formal organisations the role of social capital in influencing resilience there were four key findings about how social capital influences resilience first the ability of households to and operated as a strategy for households to cope more effectively with crises and while directly contributing to reactive resilience this is important for all forms of resilience building bridging and linking social capital were also important in the immediate aftermath of crises for enhancing access to new information resources and support to address immediate and future material losses eg access to building materials and financial aid bonding combined with limited bridging social capital however was shown to limit whether and how a need for change is perceived and acted upon such as collectively recognising climate change as a threat but with factionalised views on the type of action and change required thus the collective learning needed to improve responsive resilience can be helped or hindered through different combinations of social capital tensions around the distribution of resources in the immediate aftermath of crisis led to a longerterm loss of bridging and linking social capital for example community relationships between households were weakened from competition for accessing scarce external support existing norms that emphasised community support fostered the development of social capital prior to crises while also reducing tensions during crises thus preventing potential losses of social capital in the future once a crisis had abated thus underlying sociocultural norms focused around community support and cohesion may support resilience building over time by both encouraging the development of social capital and buffering against potential losses from conflict as communities move through periods of scarcity finally crises created space for learning about how to strengthen a local settings to reduce future negative consequences specific crises can contributed to responsive resilience as the community learnt and updated its understanding of issues and factors hindering resilience generally critical aspects affecting whether learning contributes to responsive resilience were the distribution of learning the type of learning and whether and how this learning informs collective decisionmaking social capital however can also limit learning and decisionmaking if it excludes different perspectives and learning practices thus although social capital can support experiential learning the type of learning that emerges and for who and thus the type of resilience that unfolds varies across contexts these results show that social capital has an important yet dynamic role in resilience framed in terms of shocks and crises this role is often explained in terms of more visible structural dimensions of social capital and the distribution of resources and learning however less visible dimensions are also important to shape structural dimensions of social capital and for learning and accessing resources for example social norms can lead to tradeoffs between structural types of social capital can mediate tensions and their impact and how learning informs action thus social network structures interact with less visible underlying social norms to help shape the type of resilience that emerges for resilience and climate change practice working with structural aspects of social capital is important for overcoming climate shocks to build proactive resilience and engage with the many aspects of climate change and future uncertainties involved there is a need to work with less visible dimensions within communities this is important to support social capital in ways that shape action suited to diverse settings and actors and to enhance flexibility for the future factors interacting with social capital to influence resilience there were a six key findings about different factors that interacted with social capital to influence resilience first while social networks were widely found to be a key resource for times of change a range of other factors were important including natural resources livelihoods knowledge and experience the built environment and financial resources that together shaped decisions and actions for resilience studies often emphasised different combinations of factors such as the importance of natural capital in rural settings and physical capital in more urban settings this reflects differentiation of potential resources across settings at the community level and highlights a need to consider the role of multiple factors for shaping community resilience second social capital interacted in complex ways through feedbacks with other social human cultural and natural factors to shape goals and practices over temporal and spatial scales in these studies faster changing factors were suggested to have overall much less importance than slower changing factors even for reactive and responsive resilience furthermore social capital was deliberately developed by community actors to strengthen other factors for proactively enhancing resilience this highlights the importance of considering slowchanging factors in shaping different types of resilience over longer timeframes empirical studies also suggested that social capital is important but insufficient in shaping resilience for those who are marginalised excluded or in contexts of high social inequality here other influential factors constrained opportunities for resilience such as in systems where bribery is common thus hindering access to resources for some in such circumstances no matter how much social capital is available there was limited possibility for building proactive resilience when resources within or outside communities were available but difficult to access as social capital helped gain access to new opportunities and resources and thus helped enhance resilience the key point here for building resilience is that although social capital may be central for shaping action the type of outcomes that unfold are also shaped by the availability of other resources fourth different combinations of social capital such as bonding bridging and linking were also found to be important for achieving different objectives for example a combination of high bonding bridging and linking social capital was found to be important for expressions of autonomy at the community level whereas bonding capital was important for consolidating community identity different social networks within communities the connections between them and the multifunctionality of these networks provided flexibility through time to mobilise different resources in relation to a range of events from natural hazards to infrastructure failure the implication for community resilience practice is that collective goals and visions and how they are pursued will vary and this is inpart shaped by different configurations of social capital fifth social capital can change over time short time frames as actors proximity needs routines and practices shifted eg as crises unfolded and as neighbours were dispersed in social settings with limited resources this led to a loss of resilience in the long term such disruption also created opportunities to form new relationships and shape new shared initiatives to meet arising needs and to spread ideas and information for enhancing responsive resilience this highlights that although precrisis social capital is important for resilience to shocks the disruption involved can alter social capital in the long term finally sociocultural factors associated with social capital played a substantial role in shaping resilience norms values and identities influenced the form and function of networks such as exclusionary norms that lead to isolated factions hindering the development of bridging social capital or norms that perpetuated unsustainable practices cultural norms that contribute to collective agency related to good neighbourliness solidarity and activism communitylevel sociocultural factors were also identified as important in shaping how social capital was applied in enhancing resilience eg shaping acceptance of the status quo and thus the ability to collectively imagine an alternative future specific factors that had particular symbolic value for community identity were also shown as important for collective agency and if social capital was actively pursued as a resilience building strategy thus sociocultural dimensions within communities shape connections between agency social capital and resilience for practice this implies the need to work with sociocultural dimensions within social capital to guide how community resilience unfolds these results show social capital is one of many factors that dynamically interact to shape resilience social capital can be actively used to access hardtoreach resources and shape other aspects of communities however for resilience building over longer timeframes interconnections between slower changing factors are particularly important these include social and human capital and underlying sociocultural factors such as values social norms and collective identities that shape overarching goals perceived resources and collective agency thus systems perspectives and the active engagement of multiple interconnected factors including social capital and the underlying sociocultural factors involved need to incorporated into community resilience building strategies with the complexities of climate change proactive types of resilience practice needs to account for multiple interacting factors and scales while maintaining flexibility for the future such factors influence collective visions goals and perceived needs at the community level for building resilience the relevance of social capital for shaping actions what emerges and for whom the ability to guide and work with social capital in combination with other factors is important to avoid overly simplistic approaches to social capital and resilience in terms of climate change this is important for applying systemic approaches in practice consideration of different challenges and for building inclusive positive climate narratives to strengthen resilience practice the influence of formal organisations on the role of social capital for resilience four key findings were also identified around the influence of formal organisations in shaping the role of social capital for resilience this included a focus on ideas decisions and actions of different organisations and national and local level programmes and government policies first decisions at higher levels of government were found to shape local decisions and practices that reduced social capital and resilience for example by altering power dynamics between actors and changing the way they interacted bridging and bonding social capital was eroded this loss of community resilience occured through ideological shifts in nationallevel policy processes eg towards marketbased approaches that increase competition between local producers or towards technical rather than holistic solutions for community resilience the role of social capital can be unintentionally eroded overtime through government change programmes second limited linking social capital between local organisations and communities led to missed opportunities for coordinating different resources this lack of social capital can cause a mismatch between actions of communities and local organisations better coordination can emerge from regular interactions between actors and improve the quality of social capital for the future this highlights that social capital is a dynamic resource that can be strengthened when activated over time to enhance resilience third some formal organisations provided support via funded programmes and linking social capital these are important for enhancing community resilience in direct or indirect ways that in turn enhanced social capital here the presence of linking social capital between formal organisations and communities shaped programme outcomes such as increasing access to critical financial support and indirectly supporting the development of social capital within communities this highlights that formal institutions can have a role in strengthening social capital for building community resilience however in practice the effectiveness of such interventions is shaped by linking types of social capital finally sociocultural dimensions of relations between communities and local organisations were suggested to shape community resilience indirectly for example perceptions of injustice in the practices of formal organisations may indirectly hindered social capital by exacerbating tensions between communitylevel actors formal organisations with topdown leadership approaches often lacked a social capital mindset that may not create sufficient space for communities to lead decisionmaking to understand and address current and future needs for improving responsive resilience furthermore practices with formal organisations that overlooked the role of social capital led to indirect unintended losses of social capital and limited opportunities to enhance community resilience this suggests practices and norms within formal organisations are important for shaping community resilience and over time the role of social capital in these processes these findings show that formal organisations are important actors for shaping the nature and role of social capital for community resilience at a national level policy paradigm shifts may alter the nature of social capital and thus the accessibility of resources for different actors at a community level the behaviour attitudes and actions of organisational actors may directly and indirectly influence the nature of social capital and its role in resilience building for resilience and climate change practice this emphasises the need or enabling policy environments for strengthening the role of social capital and for shaping resilience approaches more broadly to better enable proactive resilience building at the community level such policy environments need to help bring diverse perspectives ideas and capacities together and adopt a social capital approach to create spaces for exploring learning and synergistic actions critical knowledge gaps for studies of resilience social capital and climate change the previous sections examined conceptualisations and empirical insights about the role of social capital for resilience drawing out insights for community resilience and climate change practice this section identifies four critical knowledge gaps to advance understandings on this subject for researchers and practitioners why and how outcomes emerge through social capital not just what emerges across this diverse body of literature understandings of the role of social capital are often framed in terms of type of social capital eg bonding bridging andor linking social capital or strong and weak ties that connect different types of actors and in terms of outcomes such as learning and access to resources this strong orientation towards structural understandings of the role of social capital however provides limited insights to understand how and why different outcomes unfold empirical findings suggest that the binary existence of social relationships and networks appears to be less important than the nature of those relationships in shaping what emerges for enhancing resilience improving understanding about why and how different outcomes unfold through social relationships requires greater attention to a wide diversity of factors that influence the nature of social capital as well as different perspectives and goals that also influence decisions that shape actions and types of resilience addressing this gap is important to better understand how to guide social capital approaches in practice for engaging with complex challenges such as climate change in ways that support proactive resilience building at the community level dynamic interactions between different factors and social capital over time different factors resources and or capacities are emphasised within conceptual understandings of resilience alongside social capital conceptually this includes a focus on the importance of slowchanging capitals for shaping resilience empirical studies have tended to focus on tangible factors eg infrastructure and indicators of economic development in the emergency planning literature with an emphasis on reactive resilience there is limited empirically understanding about how multiple factors dynamically connect and influence each other across levels to reinforce or dampen resilience capacities better understanding of the dynamic relationships between social capital and other diverse factors is particularly important for resilience that explicitly recognises the need for change the systemic nature of climate change and the potential for factors to combine in ways that may enhance or weaken community resilience through time this is important to develop understanding of resilience as a complex social process and how to nurture it in practice different ways formal organisations can shape social capital and community resilience formal organisations are often emphasised both conceptually and empirically as important in shaping the role of social capital for community resilience currently studies tend to adopt topdown hierarchical perspectives that assume formal organisations and policies direct resilience building and often focus on reinforcing the status quo this may hinder engagement at the community level with the complexities of climate change for proactive forms of resilience to emerge by ignoring questions of unequal power relations opportunities are missed to improve understanding about the different ways formal organisations could potentially support social capital and resilience in communities alternative perspectives on approaches within formal organisations are rare particularly for supporting proactive resilience at the community level such perspectives may involve examining how formal organisations can flatten hierarchies by altering the dynamics between actors and creating space for the codevelopment of locally relevant resources and actions for resilience this may involve a subtle shift in focus towards shaping change within formal organisations to enhance social capital approaches in practice for proactively building community resilience in the context of climate change sociocultural dimensions shaping the nature and role of social capital for community resilience sociocultural factors are often conceptually underplayed when these factors are considered this is often within studies that examine social capital in relation to proactive resilience processes such as how values and norms influence foresight reflection experimentation and learning and hence resilience this includes a particular focus on social norms of exclusion in limiting the role of social capital in resilience for marginalised social groups empirical aspects of studies however highlight the role that less visible sociocultural dimensions play in social capital within different community resilience processes such as norms of community support such dimensions shape meanings attached to ideas goals resources and interactions between actors and thus in part influence the type of outcomes and who benefits yet such sociocultural considerations are not common especially in studies focusing on resilience at the community level however the need to consider such factors in change processes and engage with social justice challenges is increasingly recognised improving conceptual recognition and empirical knowledge on how sociocultural dimensions shape community resilience processes and the nature and role of structural aspects of social capital in these processes is therefore critical for understanding how different local needs and aspects of climate change are incorporated into resilience building processes addressing these knowledge gaps will involves interpretivist perspectives to build on the positivist ways of thinking about social capital and resilience that currently dominate this is important for more nuanced understandings about the role of social capital and how to guide communitylevel resilience building that engages with the complexities of challenges like climate change better understanding how the different dimensions of social capital interact to shape the form of and different outcomes from social networks and relationships and how social capital interconnects with other factors within community resilience building processes are important for informing practice however without intervention that explicitly engages with multiple interconnected challenges to enhance resilience the potential for erosion of community resilience over time is much greater thus greater attention must be paid to proactive forms of resilience its sociocultural aspects and how to work dynamically through social capital and with other factors to strengthen approaches goal and actions to guide this in practice conclusion this review synthesised conceptual and empirical understandings of the role of social capital in resilience and implications for community resilience and climate change practice multiple conceptualisations of resilience social capital and its role are highlighted while resilience was often framed in terms of shocks and maintaining the status quo social capital often involved a strong emphasis on structural dimensions with sociocultural elements underplayed this influenced how the role of social capital in resilience was understood with a strong emphasis on the quantity and diversity of social capital other factors alongside social capital and the influence of formal organisations empirical findings therefore reiterate the importance of social capital for community resilience while showing the complex ways they can interact the many nuances in empirical findings such as potential for certain forms of social capital to constrain community resilience suggest underlying sociocultural factors are particularly key they shape structural dimensions of social capital and what emerges to contribute to different types of resilience social capital approaches therefore provide important leverage for catalysing action to build resilience however resilience and climate change research needs to go beyond simplistic structural accounts of social capital to focus more on sociocultural factors and how different factors interact across social levels and over time to shape different approaches actions and outcomes this is important for enabling more systemic proactive approaches to community resilience to fully engage with complex interconnected climate change challenges

social capital is considered important for resilience across social levels including communities yet insights are scattered across disciplines this metasynthesis of 187 studies examines conceptual and empirical understandings of how social capital relates to resilience identifying implications for community resilience and climate change practice different conceptualisations are highlighted yet also limited focus on underlying dimensions of social capital and proactive types of resilience for engaging with the complex climate change challenge empirical insights show that structural and sociocultural aspects of social capital multiple other factors and formal actors are all important for shaping the role of social capital for guiding resilience outcomes thus finding ways to work with these different elements is important greater attention on how and why outcomes emerge interactions between factors approaches of formal actors and different sociocultural dimensions will advance understandings about how to nurture social capital for resilience in the context of climate change

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results multivariable logistic regression analysis showed that subjects who participated in frequent physical social and religious activity had an adjusted odds ratio of 081 087 and 078 respectively compared with participants who did not participate in each activity participants who participated in only one type of activity frequently and participants who participated in two or three types of activities frequently had an adjusted odds ratio of 086 introduction depression in the elderly is a public health concern attracting worldwide attention ongoing research is focused on relevant biological psychosocial and environmental risk factors in the past few decades intensive efforts have been made to identify psychosocial risk factors for depression that allow modification and intervention 1 2 3 4 while medication and various types of psychotherapy are still the primary treatment options for depression in the elderly lifestyle modification has recently received attention as a safe and lowcost option for augmenting the management of depression 5 among various lifestyle factors participation in physical and social activity has attracted much research attention researchers have found relatively consistent and strong evidence for the efficacy of these activities in improving mood 6 7 8 in addition owing to the current emphasis on spirituality participation in religious activity has recently attracted research attention from psychiatrists and geriatricians as a factor responsible for increasing resilience or improving mood 9 in the present study we investigated the association between these three promising lifestyle factors and the risk of depression in the elderly through a communitybased 3year longitudinal study in korea participation in physical activity was the first subject of our interest a recent systematic review suggested that various types of physical activity including elements of endurance and strength training have a protective effect in the elderly against depression severity 10 these activities usually include a moderateto highintensity exercise program at a frequency of 3 to 5 times weekly 30 to 50 minutes per session for 3 to 4 months the protective effects of physical activity involve various neurobiological mechanisms including increased neural plasticity and neurochemical change as well as some psychosocial mechanisms including selfefficacy and a sense of mastery 11 12 13 14 participation in social activity is the second subject of our interest according to the world health organization social activity is an important component of active aging 15 indeed preceding research has suggested that participation in social activity such as a neighborhood association retired or elderly association or charitable association alleviates depressive symptoms 1617 in addition a recent systematic review of interventions for social isolation suggests that social activity in a group format was more likely to be beneficial compared to a onetoone format 18 the protective effects of social activity involve various psychosocial mechanisms including increased social support and buffering of distress 17 19 20 21 participation in religious activity is the third subject of our interest this subject has recently been attracting more attention a few studies have suggested that participating in religious activity on a regular basis is a protective factor for older adults mental health and protects against common mental disorders including depression 9 22 23 24 25 26 however some of these studies were based on a crosssectional design from which it was difficult to draw conclusions regarding causality 92426 a few studies based on a longitudinal design included only limited subjects such as patients who were ill or had insufficient numbers of subjects 222327 the protective effect of religious activity involves neurobiological and psychosocial mechanisms including increased cortical thickness and resilience 28 29 30 considering the aforementioned promising protective effects of physical social and religious activity participation there is clearly a need for a largescale longitudinal study involving the elderly in local communities additionally the subject of the necessity for a study pursuing concrete evidence for the correlation or combination effect of these activities rather than simple presumption has continuously been raised 31 the main objective of the present study was to assess the longitudinal association between physical social and religious activity participation and the risk of depression in the elderly we investigated not only the effect of each type of activity but also combinatorial effects in contrast to preceding studies that focused mostly on the functional or qualitative aspects of a single risk factor we quantitatively evaluated the three risk factors in combination 21 32 33 34 a balance between these two approaches would provide the theoretical foundation for development of an intervention in the area of community mental health service to induce behavioral changes in elderly 35 methods study sample the institutional review board at keimyung university which administered the survey approved the study protocol at baseline participants were informed of the survey and invited to participate via telephone approximately 4 weeks later trained interviewers from hankook research visited participants houses and obtained written informed consent and the full survey and questionnaire participants responded to the living profiles of older people survey conducted by the ministry of health welfare and family in korea the lpops was planned as a nationwide 3year interval longitudinal survey and was initiated in 2008 we applied the geographic and demographic information based on a twostage stratified cluster sampling method first the data were stratified by seven constituent metropolitan areas and nine constituent provinces that were further stratified by urban and rural area the participants were then divided into to the 25 secondary geographic strata the geographic stratification covered all 16 metropolitan areas or provinces in korea sampling within secondary geographic strata employed auxiliary stratification indices such as gender ratio and average age obtained from surveys to yield a representative sample the baseline assessment wave 1 was conducted in 2008 and a followup assessment wave 2 was conducted in 2011 of the 19007 noninstitutionalized elderly aged 60 years who were invited to lpops 15146 completed the baseline assessment the response rate of lpops at the baseline assessment was 797 at the 3 year followup of the baseline participants 902 of the elderly patients had died and 4241 had not completed the survey due to refusal hospitalization institutionalization or loss of contact this resulted in a final followup sample of 10003 a more detailed description of the lpops is available elsewhere 3637 we included participants who completed both waves and excluded those who met the following criteria visual impairment hearing impairment language impairment cognitive impairment and depression at baseline the exclusion process was done to remove the effect of other conditions which could have a negative influence on engagement in the activities under study a total of 6647 participants were included in the final analysis measures depression depression was the primary outcome of interest in our study it was measured using the korean version of the 15item geriatric depression scale which was introduced by sheik and yesavage and translated into korean by bae and cho 3839 sgdsk scores range from 0 to 15 and are highly correlated with the 30item korean version of the geriatric depression scale a communitybased study in korea suggested that the optimal cutoff point for screening major depressive disorder was a sgdsk score of 8 or higher and the sensitivity and specificity of the findings was 936 and 760 respectively the sgdsk had satisfactory reliability and validity 40 physical activity participation abovemoderate physical activity participation was one of our primary interests and it was assessed with verbal questions posed by trained interviewers participants were asked how often do you participate in abovemoderate physical activity in a week this includes activities such as power walking swimming table tennis badminton participation in physical social religious activity and depression stretch exercises dancing yoga etc eight responses were available for the first question ranging from 0 no physical activity to 7 daily participants who responded with at least 1 physical activity per week were asked for how long do you participate in abovemoderate physical activity at once based on existing research and the distribution of responses in our study we defined frequent abovemoderate physical activity participation as 3 times a week and at least 30 minutes per activity 1141 the percentage of participants who had frequent abovemoderate physical activity participation was 198 social activity participation religious activity participation participation in social activity and religious activity were also among our primary interests and these were assessed with verbal questions posed by trained interviewers participants were asked do you participate in social activity this includes activities such as senior center hall for the elderly fraternities reunions clan gatherings etc and do you participate in religious activity this includes activities such as church catholic church temple etc yes or no responses were available for the question participants who responded in the affirmative were asked how often do you participate in that activity five responses were available for the second question ranging from 1 once or twice a year to 5 equal to or more than 4 times a week based on existing research and the distribution of responses in our study we defined frequent social or religious activity participation as participation in 1 activity per week 314243 the percentage of subjects with frequent participation in social and religious activity was 264 and 250 respectively group classification by physical social and religious activity participation we subsequently classified participants into three groups based on responses to questions on participation in physical social and religious activities group a consisted of participants who responded that they did not participate in any type of physical social or religious activity frequently group b consisted of participants who responded that they participated in only one type of activity frequently group c consisted of participants who responded that they participated in two or three types of activity frequently as a result 2901 participants were classified into group a 2826 participants were classified into group b and 920 participants were classified into group c covariates covariates assessed in the study were age gender education quartiles of household income smoking alcohol intake number of diseases disability cognitive function and baseline sgdsk score only diseases that were diagnosed by a physician were included in the number of diseases our questionnaire included four cardiovascular diseases two endocrine diseases four musculoskeletal diseases three pulmonary diseases three eye and ear diseases oncologic diseases three gastrointestinal diseases four genitourinary diseases and other diseases disability was measured using the korean version of the instrumental activities of daily living scale the kiadl includes 10 questions on instrumental daily living and scores range from 10 to 33 lower scores indicate a higher capability of instrumental daily living the kiadl has satisfactory reliability and validity 4445 cognitive function was measured with the korean version of the mini mental state examination the mmsekc includes 26items for temporal orientation registration recollection concentration calculation language understanding and judgment mmsekc scores range from 0 to 30 higher scores indicate a higher level of cognitive function a communitybased study in korea defined the cutoff point on the mmsekc for screening dementia as a score of 16 and the sensitivity and specificity of the findings were 768 and 900 respectively the mmsekc had satisfactory reliability and validity 4647 a trained interviewer used a written questionnaire to assess other covariates statistical analysis descriptive statistics to summarize the data and crosstabulation to identify their distribution were performed categorical variables were compared using the chisquare test for trend and continuous variables were compared using an anova for each of the groups based on activity participation correlation analyses between the three activities were conducted using the phi coefficient depression was assessed by sgdsk score after checking for collinearity multiple logistic regression analysis was conducted to examine the association of activity participation and risk of depression in the elderly we built the first model with all the covariates and the three individual activities and a second model with all the covariates and the group classification variable the hosmer and lemeshow test was used to confirm goodness of fit for the logistic regression model unadjusted as well as adjusted odds ratios were presented using a 95 confidence interval after that multiple linear regression analysis was conducted to examine the association between activity participation and depressive symptoms in the elderly a pvalue 005 was considered statistically significant spss software version 180 was used for all analyses results general characteristics of participants the general characteristics of the participants are provided in table 2 of the 6647 participants without depression at baseline 1443 of the participants had developed depression at followup the age range of the total participants was 60 to 95 years and the mean age of the participants was 698 years approximately 445 of the participants were men and 555 were women among the total participants 765 had some form of formal education of these 427 had elementary school level 273 had middle to high school level and 65 had college level education household income was categorized into a quartile variable based on the 15146 persons in wave 1 approximately 140 of the participants were current smokers and 376 were current drinkers the mean number of diseases was 18 the mean kiadl score was 104 and the mean mmsekc score was 249 there were statistically significant baseline group differences in age gender education smoking number of diseases kiadl score mmsekc score and sgdsk score correlation between physical social and religious activity participation correlation analyses between the three activities were conducted using the phi coefficient among them participation in social activity and religious activity were not correlated with participation in physical activity only participation in social activity was weakly correlated with religious activity but its effect size was not large longitudinal association between physical social and religious activity participation and risk of depression at followup in the multivariable analysis age gender education household income smoking alcohol intake number of diseases kiadl score mmsekc score and sgdsk score were regarded as covariates multiple logistic regression analysis was conducted to examine the association of activity participation and risk of depression in the elderly we built the first model with all the covariates and the three individual activities and a second model with all the covariates and the group classification variable in the first model participants who participated in physical activity 3 times weekly had an adjusted or of 081 compared to participants who did not participants who participated in social activity and religious activity 1 time per week had adjusted ors of 087 and 078 respectively compared to participants who did not in the second model participants who participated in only one type of activity frequently and participants who participated in two or three types of activity frequently had adjusted ors of 086 and 064 respectively compared to participants who did not participate in any type of physical social and religious activity frequently multiple linear regression analysis was also conducted to examine the association between activity participation and depressive symptoms in the elderly using similar approach discussion the results showed that participation in physical social and religious activity was associated with decreased risk of depression in the elderly after adjusting for known confounding factors the odds of depression decreased by 19 in the elderly who engaged in physical activities 3 times weekly with at least 30 minutes per activity the odds of depression also reduced by 13 and 22 among elderly who engaged in 1 social activity and religious activity weekly respectively our communitybased 3year longitudinal study suggested not only that each of the three types of activity is individually associated with a lower risk of depression but also that the combination of two or three types of activity is associated with much lower risk of depression the odds of depression reduced by 36 among elderly who engaged in two or three types of activity compared with the elderly who did not participate in any type of physical social and religious activity the significance of the current study lies in the fact that it is the first comprehensive approach that has been developed to the best of the authors knowledge to evaluate the protective effects of the three variables ie physical social and religious activity participation the protective effects of these variables have been demonstrated in this study development of methods for reducing the risk of depression in the elderly has thus far been a critical issue in the field of community mental health service many researchers individually proposed different psychosocial risk factors that were considered important from their own viewpoints and also conducted relevant intervention studies 4849 in practice however mental health promotion for the elderly in the community seldom targets only a single risk factor but usually targets various risk factors of similar characteristics simultaneously accordingly the necessity of research pursuing concrete evidence on the correlation or combination effect of these activities not just presumption has continuously been cited in the current study we demonstrated that the combination of two or three types of activity further reduces the risk of depression in addition the insignificant or negligible correlation between these three activities which are thought to be similar and interactive is considered an important and meaningful finding for developing a mental health promotion or intervention study few preceding studies have suggested similar results 263150 therefore future mental health promotion or intervention studies on physical social and religious activity need to be undertaken and emphasized independently to strengthen their protective effect unfortunately the present research did not involve an intervention study design and therefore could not provide a completely satisfactory answer in addition consideration of diverse variables together made it difficult to adequately explain the mechanism of the protective effects nevertheless our evidencebased approach is very specific intuitive realizable and relatively easy eg you can reduce the risk of depression by taking part in three sessions of physical activity weekly each session lasting more than 30 minutes one session of social activity weekly and one session of religious activity weekly intervention studies would be necessary in the future for further experimental evidence in addition this cutoff point should not be considered an absolute value because other factors such as the sociocultural characteristics would also have to be considered the study had multiple strengths first study subjects were from a relatively large nationwide longitudinal communitybased survey in korea second adjustment was not restricted to definite or potential demographic risk factors for depression but also to clinically important risk factors such as smoking drinking comorbidity disability cognitive decline and baseline depressive symptoms finally the present study defined intuitive and easytomeasure independent variables and achieved positive results the study therefore presented further evidence for planning an intervention study or public campaigns related to lifestyle factors despite its strengths our study had some limitations first the assessment of depression was based on a screening tool rather than a definite diagnostic measure or clinical interview by a doctor second owing to the observational design of the study unmeasured confounders may have resulted in biased outcome third the physical social and religious participation of the study participants could not be fully confirmed through an interview but depended on their responses to a survey such limitations could also lead to recall bias therefore to minimize recall bias subjects who showed cognitive decline were excluded fourth the representativeness and generalizability of our study were limited this limitation could result from selection bias which was probably a consequence of the initial recruitment process conducted via telephone and the application of operational inclusion and exclusion criteria for the lpops in addition insufficient consideration of regional social context which cannot be covered by single level regression analysis could also limit the representativeness and generalizability of this study fifth insufficient information about the quality and quantity of physical activity from the selfreported nonstandardized measure is another limitation that must be acknowledged future work is needed to attain a more specific validated measure such as a metabolic equivalent 51 sixth the study addressed only the quantitative aspects and not functional or qualitative aspects of the three types of activity considering the variability in physical social and religious activities future research requires focusing on specific details and qualitative aspects of the aforementioned lifestyles finally group classification in the present study made it difficult to provide a sufficient explanation or mechanism for the combinatorial effect of activities on depression conclusion participation in physical social and religious activity was associated with decreased risk of depression in the elderly in addition the risk of depression was much lower in the elderly who participated in two or three of the abovementioned types of activity than that in the elderly who did not data from the lpops study are available upon request to researchers who meet the criteria for access to confidential

we examined the longitudinal association between participation in individual or combinations of physical social and religious activity and risk of depression in the elderlyelderly subjects aged 60 years who completed the living profiles of older people survey in korea n 6647 were included the baseline assessment wave 1 was conducted in 2008 and a followup assessment wave 2 was conducted in 2011 we defined participation in frequent physical activity as 3 times weekly at least 30 minutes per activity frequent participation in social and religious activity was defined as 1 activity weekly the primary outcome was depression at 3year follow up

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introduction background men who have sex with men suffer disproportionately from a wide range of health conditions the most studied of them being their susceptibility to hiv infection indeed msm represent 70 of new hiv diagnoses in the united states of america 1 and more than half of new hiv diagnoses in the european unioneuropean economic area 2 furthermore they are also more prone to contract other sexually transmitted diseases and gonococcal isolates from msm are more likely to exhibit strengths and limitations of this study ► this proposed review will be the first scoping review to map the current knowledge in syndemic theory applied to men who have sex with men an important topic to understand the complex interactions between avoidable health conditions within an already vulnerable population group ► a comprehensive search strategy of electronic databases was developed with the help of the director of health sciences library of our institution this will be combined with a secondary handsearch of reference lists of included studies ► we plan to conduct a fully transparent and reproducible study so that another researcher could reproduce our analysis using our openaccess data and codes ► grassroots lgbtqia and community health organisations will be the focus of the dissemination phases as part of a larger project to improve the health of msm in belgium ► usual limitations of scoping reviews will apply such as the lack of risk of bias and strength of evidence assessment however we feel that the heterogeneity of research in the field of syndemics means a scoping review is the most appropriate methodology at this time open access antimicrobial resistance than samples taken from heterosexual men 3 in addition to the burden of hiv and other sexually transmitted infections msm are also more likely to suffer from mental health conditions depression anxiety suicide attempts and selfharm are more prevalent among msm 4 5 6 substance use is also higher in the msm population 7 moreover all of these negative and often avoidable health outcomes are associated with experiences of homophobic violence stigma discrimination internalisation of negative assumptions and attitudes about msm by msm themselves 8 9 10 11 12 as well as with poverty unemployment unstable housing and poor healthcare access 13 14 15 16 unfortunately social factors such as these are often overlooked in the conventional frameworks of comorbidity and multimorbidity 17 even though our understanding of diseases clustering demonstrates the need to incorporate social and environmental elements 18 to offer meaningful improvements to the health of marginalised populations public health researchers and clinicians must move beyond a reductionist understanding of disease causation to more complex models of diseases interaction taking into account the social forces driving health inequalities 18 19 20 syndemic theory draws attention to how social economic and environmental factors affect the health of individuals 18 a syndemic refers to two or more mutually reinforcing epidemics interacting to produce an excess burden of disease in a population because of harmful social conditions 21 the main appeal of syndemic theory is that it considers health with a holistic point of view describing interactions at two levels between diseases themselves and between diseases and the social environment that contributes to their emergence clustering and spread 18 one example of biological interaction between diseases would be the hivhepatitis b virus coinfection that results in a faster course of the liver disease and an increase in the risk of hepatocellular carcinoma 22 for biosocial interactions relevant to our population of interest we may cite the heightened stress due to the stigmatisation and various forms of violence msm encounter that may lead to unhealthy coping mechanisms such as drug and alcohol abuse as well as mental health disorders including depression and anxiety 23 these dysfunctional coping strategies and mental health issues may in turn trigger sexual risk behaviours increasing the risk of infections such as hbv and hiv 18 24 to return to our previous example thereby syndemic theory provides an appropriate framework to study the health disparities among msm and the links between these disparities and averse social conditions such as homophobia and structural heterosexism rationale as promising as syndemic theory is to explain health disparities among msm and to propose multidisciplinary interventions empiric data supporting this theory remain limited 25 26 indeed in a systematic review conducted in 2015 on psychosocial problems and hiv risk tsai and burns 25 showed that although the concept of interaction is central to the theory statistics used to assess interaction vary considerably across studies and are often inadequate to prove the existence of an interaction moreover in a scoping review of syndemicrelated publications performed by singer et al 27 published in 2020 the authors found only a limited number of citations meeting the definition of a true syndemic among the recent research in the field indeed most publications related to syndemic theory failed to articulate the biological and biosocial interactions necessary to account for a true syndemic 27 these findings highlight the challenges faced by researchers interested in this approach to describe and empirically support a syndemic arrangement as well as a deviation from the original conceptualisation of the syndemic theory 27 a scoping review of systematic reviews on hiv prevention research on msm published between 1988 and 2017 found that syndemics were an understudied topic 28 mapping current knowledge in this field is important given the evolving variation in methodological approaches in syndemic research and the potential of the syndemic framework to address health inequalities and improve care and prevention services for this vulnerable population objectives the goal of this scoping review is to provide an overview of the existing literature on syndemic theory applied to msm we seek to map 1 the different study designs employed 2 the subpopulations of msm studied 3 the outcomes measured 4 the psychosocial conditions evaluated and how they were defined 5 the statistics used to evaluate the concept of interaction 6 how many studies proposed a hypothesis for biological and sociobiological interactions and to collect the hypotheses proposed when applicable the information gathered will allow us to better understand the state of affairs in this topic to identify the current knowledge gaps and to suggest recommendations to guide future research in the field in order to expand our understanding of the complex interactions between avoidable health conditions in a vulnerable population methods and analysis design scoping reviews have been defined as a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts types of evidence and gaps in research related to a defined area or field by systematically searching selecting and synthesising existing knowledge 29 this kind of review is relatively new and has become increasingly open access popular in recent years 30 it is a suitable approach for our research given that we do not intend to evaluate the quality of the included studies nor the strength of their findings the methodology of our scoping review will apply the framework suggested by arksey and omalley 31 with enhancements from levac et al 32 we will also take into account the recommendations from colquhoun et al 29 and peters et al 33 furthermore we will follow the preferred reporting items for systematic reviews and metaanalyses extension for scoping reviews 34 the completed checklist can be found in online supplemental table s1 screening and data charting will be completed using distillersr statistics charts tables and final report will be generated using r 35 rstudio 36 and relevant packages we took several measures to ensure full transparency and reproducibility of our research and the complete data management plan can be found in the supplementary materials this protocol was registered on manuscript submission on the open science framework and every important protocol amendment that may happen will be documented there stage 1 identifying the research questions the overarching research question of this scoping review is what is known about syndemic theory applied to msm to better explore this main question we identified three subquestions 1 how are studies concerning syndemic theory applied to msm conducted 2 how is the concept of interaction explored in syndemic research applied to msm 3 what were the key findings of these studies the questions 1 and 3 allow us to explore the full scope of the field and to summarise the way research is done and what was found so far it is worth mentioning that as stated earlier we seek to map the field not to assess the strength of the evidence and the risk of bias question 2 aims to address the limitations already known on syndemicrelated publications 25 to explore how they apply to the publications restricted to the msm population as such we will investigate both the statistics used to demonstrate an interaction and how the authors articulate the biological and biosocial interactions needed to account for a true syndemic arrangement stage 2 identifying relevant studies to identify the relevant studies we employed a systematic search strategy with the help of the head librarian of our institution we selected the following databases medline psycinfo scopus cochrane central register of controlled trials and proquest sociological abstracts to allow us to obtain studies from different fields to have the most comprehensive corpus possible the main challenge we faced constructing the search strategy was the number of synonyms for men who have sex with men to overcome this difficulty we assembled a first list of keywords then we included additional keywords by selecting relevant entry terms for the mesh term sexual and gender minorities which encompass msm the final list of keywords was approved by the authors and by our institutions director of health sciences library to limit the scope of the research to the studies focusing on syndemic and msm we decided to restrict the search to title abstract and keywords it seemed to be the best compromise between searching the full text which may generate too much noise by returning studies that only mention msm andor syndemic and limit to the title only which may be too restrictive likewise we decided to only search articles containing syndemic in their title abstract or keywords while we recognise that some earlier literature might be ignored our goal is to examine how this concept in particular has been studied since it was conceived moreover adding other search terms is likely to return too many references for the size of our team and our time constraints no date limits will be applied given the relative novelty of the syndemic literature and the expected low number of citations using this search strategy for medline via ovid we were able to generate 184 results we then translated this search strategy for psycinfo scopus cochrane central register of controlled trials and proquest sociological abstracts which generated a total of 628 citations the full the electronic search strategy can be found in online supplemental table s2 search results will be downloaded into ris files and imported into distillersr duplicates will then be immediately deleted before study screening for inclusion after inclusion of relevant studies we will handsearch the reference lists of the included studies to manually add pertinent studies that might have escaped our search strategy the same selection process outlined in stage 3 for the electronic search will be used relevant studies identified through these steps will be marked as additional records identified through other sources in the study selection flow diagram stage 3 selecting studies the screening process will be done using forms generated with distillersr by the authors we will operate at two levels a first wave of screening will be conducted on titles and abstracts articles that meet the inclusion criteria or for which eligibility is unclear will then pass through a second wave in which the full texts will be assessed for eligibility a flow diagram will be generated to summarise the whole process and exclusion reasons will be specified to embrace the full breadth of the research conducted on the field and considering the low number of existing studies we decided to opt for broad inclusion criteria research will be included if they meet the following criteria open access ► the main population studied must be msm for the inclusion criterion purpose we consider as msm every man who has sexual relationships with other men independently from how they are defined in the study or how they define themselves they will be considered eligible regardless if they have sexual relationships exclusively with men with men and women or mostly with women ► the syndemic framework must be the main focus of the study studies only mentioning syndemic theory will be excluded articles published in the early days of syndemic research that did not use the term yet will be included if they used a syndemic lens and had an impact on the field ► studies must be cohort casecontrol crosssectional controlled trials or qualitative studies ► we will exclude letters commentaries and editorials ► language must be english ► only peerreviewed citations will be included no restriction will be applied concerning the location of the studies the age of the participants nor the date of publication because of the broadness and objectivity of our inclusion criteria we do not consider it necessary for each paper to be reviewed by the all authors instead 10 of the articles after deduplication will be randomly chosen and screened for eligibility by two reviewers a kappa interrater reliability score will be computed using distillersr to evaluate the agreement between the two reviewers a score superior to 08 will be considered sufficient 37 and the rest of the screening process will then be conducted by the main investigator only throughout the two reviewers phase discrepancy between the reviewers during the abstract screening will move the paper to fulltext assessment any discrepancy after assessing the full text will be discussed to achieve consensus if a consensus cannot be reached between the reviewers a third reviewer may be consulted for arbitration stage 4 charting the data data charting will be performed using forms generated in distillersr by the authors forms will be created to extract relevant information to answer the research questions as well as general study characteristics inspired by recommendations on data charting for scoping reviews 31 38 study characteristics not directly related to our research questions consist of author year of publication and the country where the study took place to answer our first subquestion we will extract data regarding study design location of study sample size age of the sample population and subpopulation of msm studied if any conditions studied as part of a possible syndemic and how those conditions were defined and measured and outcomes considered and how they were defined and measured and intervention type comparator and duration of intervention to answer question 2 we will chart the statistics used to prove an interaction as well as if the study provided any articulation of biological interactions and biosocial interactions and what was the proposed articulation if applicable finally we will summarise the key findings and recommendations to answer our last subquestion the forms developed in distillersr for data charting may be adapted throughout the data collection process if new characteristics of interest emerge during the course of the study any departure from the present protocol be it additional characteristics or removal of characteristics presented above will be stated and justified in the final report stage 5 collating summarising and reporting the results all data collected in stage 4 will be collated summarised and reported using r 35 rstudio 36 and relevant packages to answer the first subquestion tables will be generated to offer a quantitative summary of the data collected in addition diagrams will be used to better visualise the breadth of conditions studied as plausible syndemics and the context in which they were studied doing so we aim to provide an overview of the conditions most likely to represent a true syndemic in order to inform future research by proposing recommendations to focus on those conditions for the second subquestion we will generate a table summarising the key findings and recommendations for each study included and we will provide an overview of these findings and recommendations in the discussion for studies proposing hypotheses of interaction we will summarise said hypotheses in a dedicated table comprising the study identification the level of interaction and the proposed hypothesis of interaction finally to address the question of knowledge gaps in syndemic theory applied to msm a visual evidence gap map will be created to help identify areas in which current evidences are lacking 39 study timeline the first stage of the proposed scoping review has already been completed to develop this protocol stage 2 has been initiated and mostly completed with regards to the electronic search the ris files have not been downloaded yet and the handsearch of the reference lists will only begin after completion of stage 3 the third stage will begin shortly after manuscript submission we expect to complete this stage within a month before moving on to stages 4 and 5 which should take an additional 6 months we expect to complete the scoping review by january 2021 open access patient and public involvement the first author is also the managing director of a lgbtqia youth organisation the relevance and potential of syndemic theory to the populations represented by the grassroots organisation has been extensively discussed internally and mo has been invited to give several presentations on the topic though lgbtqia organisations have not been involved directly in the elaboration of the protocol the relevance of the research objectives to the population in question has been established lgbtqia organisations and community health organisations will be extensively involved in the dissemination phases of this project as discussed below ethics and dissemination this study does not require ethics approval as data will be collected through a review of published peerreviewed literature dissemination of the findings will first occur via submission of the scoping review for peerreviewed publication in a scientific journal in order to promote transparency and reproducibility in scientific research every file necessary to reproduce our research will be registered on the open science framework and made accessible to be reusable with appropriate citation our full data management plan can be found in the supplementary materials following publication of the study findings will be presented in an accessible format on the personal website of the main investigator and shared to the msm population through grassroots lgbtqia and health community organisations this collaboration with grassroots organisation for the dissemination of our findings could then take the form of conferences seminars or courses to draw attention to the syndemic theory moreover this paper is intended to feed into an ongoing project on the health of msm in belgium contributors all authors contributed meaningfully to the preparation drafting and editing of this scoping review protocol bs suggested the idea and offered guidance throughout all stages of protocol development mo the main investigator and guarantor of the review conceptualised the research questions and the research protocol as well as the data management plan jlb and lb participated in the elaboration of the protocol and proposed several improvements during the rounds of editing all authors approved the final submitted manuscript competing interests none declared patient consent for publication not required provenance and peer review not commissioned externally peer reviewed supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

introduction men who have sex with men msm are disproportionally affected by a number of health conditions that are associated with violence stigma discrimination poverty unemployment or poor healthcare access in recent years syndemic theory provided a framework to explore the interactions of these health disparities on the biological and social levels research in this field has been increasing for the past 10 years but methodologies have evolved and sometimes differed from the original concept the aim of this paper is to provide an overview of the existing literature on syndemic theory applied to msm in order to identify knowledge gaps inform future investigations and expand our understanding of the complex interactions between avoidable health conditions in a vulnerable population methods and analysis the proposed scoping review will follow the methodological framework developed by arksey and omalley with subsequent enhancements by levac et al colquhoun et al and peters et al as well as the preferred reporting items for systematic reviews and metaanalyses extension for scoping review a systematic search of medline psycinfo scopus cochrane central register of controlled trials and proquest sociological abstracts will be conducted reference lists of the included studies will be handsearched for additional studies screening and data charting will be achieved using distillersr data collating summarising and reporting will be performed using r and rstudio tabular and graphical summaries will be presented alongside an evidence map and a descriptive overview of the main results ethics and dissemination this scoping review does not require ethical approval data and code will be made accessible after manuscript submission final results will be disseminated through publication in a peerreviewed journal and collaboration with grassroots lesbian gay bisexual transgender queer intersex and asexual lgbtqia organisations

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introduction a destructive earthquake gives rise to a collective sense of mourning due to the loss of affective relations material goods and everyday points of reference and a consequent need to redefine living patterns the disruption of peoples lives and their loss of certainties affect their physical and mental health in both the short term and years after the calamity 1 2 3 the literature is full of papers describing the presence of posttraumatic stress disorder 4 5 6 7 8 9 10 11 12 13 14 15 16 and depressive disturbances anxiety irritability and insomnia 371114 16 17 18 19 20 21 22 23 24 25 26 27 28 29 and there is also an increase in the incidence chronic degenerative diseases and a worsening in preexisting conditions 2101725 all of these factors have a negative impact on the quality of life 21530 which is also affected by gender age physical injury and damaged housing with subsequent displacement and the dissolution of social networks 101113202425 31 32 33 the elderly are among the most affected 1011131721242627293435 because as pointed out by the who in its report active aging a policy framework their quality of life not only depends on their state of health but also on many other variables such as their social relations their recreational and cultural activities and the environment these can all play a protective role in active aging but their absence is a risk factor for physical and cognitive decline it is for this reason that we decided to investigate the elderly living in the highly urbanised area of laquila which on 6 april 2009 was struck by an earthquake that almost totally destroyed the citys medieval centre and its immediate surroundings after the emergency phase some of the people whose homes had been destroyed were relocated to 19 areas with earthquakeresistant housing which led to their decentralisation and the disruption of their social networks they found themselves living in unfamiliar surroundings devoid of services that are still little more than dormitories almost 4 years after the earthquake this has had a profound effect on the population as a whole but particularly on the elderly who are less selfsufficient in terms of mobility and having been deprived of friendships social gatherings and places of worship are now isolated and unable to reestablish their everyday lives or their contacts with friends and relations the aim of the study was to verify the impact of the change on their perceived quality of life materials and methods the study was carried out between october 2011 and march 2012 and involved 571 subjects aged over 65 years living in the municipality of laquila it investigated various factors that are important for the quality of life of the elderly and the effect that the earthquake of 2009 has had on these variables the interviews which were conducted by postgraduate physicians specialising in hygiene and preventive medicine took place in the surgeries of general practitioners and the citys department of prevention and vaccination in the antiinfluenza immunisation period the gps invited the over65 s in their surgeries to undergo the interviews and all of those who agreed were consecutively enrolled the interviews were conducted anonymously and all of the interviewees were asked to give their written informed consent after the purpose of the study had been explained to them the standardised instrument was based on one published and validated questionnaire used within a multicentric italian study carried on by national research council 36 and consisted of 36 questions with closed multiple choice answers divided into the following sections demographics everyday activities health perceived wellbeing using two visual analogue scales happinesswellbeing and physical wellbeing and the quality of life in the city before being administered to the study sample the questionnaire was submitted to a small group of elderly for testingretesting the result of which was a cohens kappa of 091 statistical analysis the characteristics of the study sample were analysed using descriptive statistics the discrete and nominal variables were expressed in terms of frequency and percentages and the differences were tested using the v 2 or fishers exact test the continuous variables were expressed as mean values and standard deviations the normality of data distribution was tested using the shapirowilk test wilcoxonmannwhitney test was used to evaluate differences by gender and housing conditions on the basis of the vas score for each individuals perceived quality of life multivariate logistic regression models were used to estimate the odds ratios and 95 confidence intervals of the associations between the need of a subject to leave hisher current housing conditions and the relative contributions made by some demographic living and perceived wellbeing variables the propensity to socialise or not was analysed on the basis of the vas scores of the interviewees c5 means the presence of perceived happiness wellbeing and b4 its absence the tests were twosided and a p value of 5 was considered significant spearmans coefficient was used to measure the degree of correlation between the answers to two questions how is your health in general expressed with a score between 1 to 5 and using a scale from 1 to 10 could you tell me how happycontent you feel in this period of your life the data were analysed using the stataic 121 statistical package the study protocol has been submitted to the institutional review board for ethical issues approval results sociodemographic characteristics of the sample of 571 elderly which included more men than women and had a mean age of 73 years their educational level was mediumlow the women were generally less educated but there were more of them at the two extremes the vast majority were living on a pension of one kind or another and only 106 declared that they were working almost a third were living in temporary homes provided by the government table 2 shows their perceived mean level of happiness wellbeing before and after the earthquake as measured by a 110 vas the scores recorded by the subjects living in temporary housing were lower than those of the subjects living in rented or owned accommodation the scores attributed to the preearthquake period were higher for both groups but particularly the former although the difference was not statistically significant when asked to judge the happiness of people of the same age the subjects living in temporary housing gave lower scores than those living in rentedowned housing and lower than those attributed to themselves analysis of this perception by gender showed that the women had a more negative view of their wellbeing than the men both before and after the earthquake although not statistically significant the subjects perception of the happiness wellbeing of people of the same age maintained the male female difference and the scores were once again lower than those attributed to themselves the interviewees were then asked whether they would like to live in another area or city and 2509 said they would putting this wish in relation to the subjects perceived wellbeing and housing conditions our data show that the probability of wishing to live in a different place was higher as the score attributed to the subjects perception of their current happinesswellbeing diminished and the score attributed to their wellbeing before the earthquake increased the association between the wish to live elsewhere and the score attributed to the happiness of people of the same age was not significant the probability of a wish to move was very high among the subjects living in temporary housing we then asked where would you like to live the answer in my previous area was chosen by 5861 of the sample whereas 287 would change it 1066 would move to another city and 2887 had no preference in answer to the question with whom do you spend your free time 2509 said with friends and only 456 with their neighbours relationships with neighbours were declared to be formal reciprocally supportive conflictual and good table 4 shows the association between happinesswellbeing and the propensity to engage in more or less socialising activities it can be seen that those with a greater perception of their own wellbeing were more likely to engage in both socialising and nonsocialising activities than those with a score of b4 the analysis of the correlation between the perception of wellbeing and health status shows that an increase of the scores given to their happycontent also improves the judgment of his state of health discussion the aim of our survey of the perceived quality of life of a sample of elderly people was to evaluate their state of wellbeing 3 years after the earthquake the sample corresponded to about 4 of the over65 year olds living in the municipality the analysis was based on the vas scores of happiness wellbeing attributed to themselves by the subjects as a measure of their perceived quality of life and this measure was used to evaluate the possible variables determining their health and social welfare particularly social activities and housing conditions as changing residence was the principal intervention after the earthquake the relationship between the trauma and morbidity seems to be clear and the effect of the mediumterm change in housing conditions on the perception of wellbeing is equally important the earthquake that struck laquila in april 2009 has had considerable repercussions on the health of the people affected numerous studies carried out after the earthquake have revealed a 37 increase in the prescriptions of antidepressants and a 129 increase in the prescriptions of antipsychotics 37 particularly among elderly women among the young there has been an increase in the consumption of alcohol tobacco and cannabis 38 a study of a sample of subjects aged 1869 years carried out by the istituto superiore di sanita in 2010 16 found that in comparison with 20072008 the occurrence of ptsd had increased ten times that of depression had increased six times and that of sedentariness had doubled mainly among over50 year olds women and relocated economic and employment difficulties are the common denominator of both ptsd and md 14 furthermore immediately after the earthquake there was a 269 increase in the number of hospitalisations due to cardiovascular diseases among the elderly 39 our data indicate that the over65 s experience a certain social isolation most of their free time is spent with their families and their relationships with friends and neighbours are rather formal as shown by the absence of conflicts and support it is also necessary to bear in mind that only 106 of our sample worked which suggests that the intervewees have a lot of free time however this is not used for socialising as very few subjects engage in activities such as sport or recreation that would bring them into contact with their contemporaries only 2509 declared they spend their free time with friends and no more than 456 with their neighbours a finding that is in line with the results of the 2010 survey reporting anhedonia and depression in 10 of the interviewees 16 the isolation of the elderly population may be due to their relocation destroying their social networks this view is supported by the findings of other studies of people involved in natural calamities which have shown that changes in housing conditions altered social networks and living far from friends and relatives increase psychiatric and quality of life disturbances 1711121520263133 whereas social support improves both 1318212230 housing conditions also affected our subjects perception of their happinesswellbeing which logically enough worsened after the earthquake particularly among those living in temporary housing analysing the data by gender showed that the women had a more negative perception of life both before and after the earthquake this is in line with the findings of other studies showing that women are more affected by the consequences of an earthquake 5 8 14 20 2224 26 30 as well as those of a recent study showing that psychiatric morbidity is greater among relocated women than women who have not had to move 40 the more negative the perception of their wellbeing the greater the wish of our subjects to live elsewhere this was particularly true of the subjects living in the new towns who longed to be able to return to their earthquakedamaged homes it is worth noting that when the interviewees were asked to judge the happinesswellbeing of their contemporaries the scores were lower than those attributed to themselves even when the variables of housing conditions and gender were taken into account as pointed out in other studies 1312263032 this is unlikely to be due to economic factors because almost all of our interviewees were living on a pension and this would not have been changed by the earthquake we can therefore state that the nexus between the change in housing conditions and the quality of life and social activities is sufficiently well documented the creation of new residential areas in laquila certainly responded to immediate need for housing but this was not followed up by the subsequent phase of creating the services and places of socialisation that could have restored a minimum of social fabric there has been a lack of the weak ties that would have allowed the elderly to confront the difficulties caused by the earthquake and their consequent relocation and an absence of sharing the problems created by the new situation in the case of a calamity public assistance should take into account the particular characteristics of different age groups as they have ceased their active role in society the everyday life of the elderly is based on affective and relational factors which help them to overcome their difficulties and allow them to feel themselves an integral part of the community after the first period during which the people of laquila received incredible support from voluntary workers the second period of relocation interrupted newly formed relationships without restoring the old also because it was not possible for familiessocial groups to coordinate their destinations laquila still has 30000 inhabitants without a permanent home and it is expected that the reconstruction will take about another 20 years many of our interviewees may not be able to return to their homes and their awareness of this affects their health mood and desire to socialise governments faced with the problems arising from a natural calamity should take into account all of the open access this article is distributed under the terms of the creative commons attribution license which permits any use distribution and reproduction in any medium provided the original author and the source are credited

on 6 april 2009 the city of laquila was hit by a violent earthquake that destroyed almost all of its medieval centre and the surviving inhabitants were evacuated and relocated in temporary quarters or undamaged homes the aim of this study was to investigate the perceived quality of life of the elderly population 3 years after the earthquake in relation to the social and logistic issues of new housing the study was carried out between october 2011 and march 2012 and involved 571 subjects aged over 65 years living in the municipality of laquila the interviews took place in the surgeries of general practitioners and the citys department of prevention and vaccination in the antiinfluenza immunisation period the instrument used was a 36item questionnaire with closed multiple choice answers divided into the following sections demographics everyday activities health and perceived health and the quality of life in the city the results show that 3 years after the earthquake the elderly population living in the new towns and temporary housing of laquila have a worse perception of their quality of life than the others they feel a certain social isolation and wish to live elsewhere governments faced with the problems arising from a natural calamity should take into account all of the elements making up a good quality of life and before making choices whose impact cannot be changed consider both their immediate and longterm social consequences

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introduction enabling aging in place has become a global imperative 12 the process involves a persons evolving circumstances throughout their life course and could include their financial situation retirement status family roles and other aspects of their social cognitive and physical functioning one of the primary goals is to support older adults in their preferred place of residence rather than transitioning to institutional care or if they are in an institutional setting to enable them to maintain functioning and independence 1 socially assistive robots may support a wide array of aspects of daily living sars vary widely in terms of social abilities and physical form factors robot care providers can be purely mobile platforms mobile manipulators or completely stationary range in humanoid features and have various autonomy capabilities and selfdirectedness specifically mobile manipulators which are robot caregiver systems with both mobility capabilities and a robotic arm for manipulation 3 can support instrumental activities of daily living such as cleaning assistance with grabbing or reaching objects in contrast exclusively socially assistive robots do not perform manipulation tasks but instead provide social support capabilities for iadls other contexts for social robots include education medicine and rehabilitation 4 by assisting with activities sars have the potential to support older adults needs in their own home and community for robots to be successfully implemented in this context they will need to be trusted by older users 56 trust is an important factor to consider when designing for longterm interactions with sars 78 robotics 2023 12 162 2 of 13 trust in robot care support within the humanrobot interaction literature several consistent factors emerge as potential determinants of trust common human factors include performance preferences for robot appearance physical touch form factors 9 10 11 safety and predictability 12 in addition user characteristics such as age and technology experience play a role in shaping trust 13 although studies have found that age can play a role in shaping human trust less research has focused on factors that shape older adults trust in robots a mixedmethod interview study by stuck and rogers 8 explored dimensions of robot care provider trust among older adults and found that robot competency and professional skills were a prominent trustdetermining theme their study also revealed a novel trust factor sociability which refers to perceptions of a robot as kind friendly polite and benevolent the study by 8 illustrated the importance of robot communication in establishing trust with subdimensions such as taskspecific communication responsiveness and interpersonal communication these findings are consistent with the findings from a general review by 14 on hri nonverbal communication in shaping users perceptions of robot politeness friendliness and trust however the relationship between robot sociability and trust among older adults still lacks quantitative and empirical evaluation robot sociability and trust sociable robots have friendly and benevolent attributes which may be associated with capabilities for understanding and appropriately responding to human social cues such as body language tone of voice and facial expression 15 robots that demonstrate empathy emotional responsiveness and adaptability and that can learn from interactions to tailor their behaviors and responses to individual users are likely to be perceived as sociable 1314 theoretically a positive relationship between robot sociability and trust can be explained in part by the social identity and similarityattraction paradigms 1617 these perspectives posit that individuals tend to trust and feel closer to interaction partners that exhibit behaviors or traits that they identify with robots demonstrating humanlike social skills politeness and emotional acuity can foster a sense of familiarity and comfort subsequently reducing perceived risks and nurturing trust 14 similarly the uncertainty reduction theory underscores that predictability and politeness during social interactions can contribute to the establishment of trust 18 aspects of robot sociability could be especially critical when considering robots to support activities in the home for older adults a sociable robots capability to engender trust and comfort could potentially mitigate apprehension that older adults might have towards robotic support in their home thereby enhancing adoption and user experience 19 overview of studies to explore robot sociability and trust among older adults we conducted two online survey studies in both studies participants were shown a series of videos of robots performing common everyday living tasks a total of six sar videos were chosen to represent three levels of robot social capabilities in performing two iadl tasks the vignettes used in the survey video stimuli were selected from a sample of robot videos evaluated by subject matter experts in the survey for study 1 the robots were shown to participants in order from lowtohigh robot social capabilities which could have engendered ordereffects and influenced participants perceptions of robot sociability and trust we conducted study 2 to implement a counterbalancing technique for how the videos were displayed to participants in addition we reexamined the robot form factors and capabilities displayed by the robots to rule out potential confounding factors that could have been present in study 1 and to assess whether the findings for the relationship between robot sociability and trust were replicated with different participants recruitment and sample characteristics we recruited participants with a snowball approach by reaching out to older adults through registries used in other studies within our laboratory as well as personal contacts and the illinois health and engagement through the lifespan project registry the participants were 51 older adults aged 6585 and intermediate or fluent english speakers who could fully understand and interpret online survey questions on average participants were highly educated married older adults living in an apartment or condominium we utilized the redcap platform for online survey data collection 20 the online survey included a consent form an image and video for each robot and questionnaires for perceived robot sociability and perceived robot trust for compensation participants were given the opportunity to provide their email to be entered into a raffle to win an amazon gift card when participants selected the web link to the survey from our email recruitment materials a consent form was presented on the redcap landing page the participants were required to read the form and consent to participate prior to viewing the next page where the survey began all procedures were approved by the institutional review board of the office for the protection of research subjects at a large midwestern university study 1 materials and measures video stimuli development to select the sample of robots to include in the survey we conducted an evaluation of existing sars social characteristics and features with hri smes our goal was to select video stimuli that represented sars that had a variety of form factors and social capabilitiessuch as the robot expressed emotions the robot communicated with users verbally or with sounds and the robot had a distinct personality we downselected from twelve to six robots by choosing robots that scored low medium and high in social capabilities across two tasks response options assessed the level of agreement 1 strongly disagree to 5 strongly agree for each item amazon gift card when participants selected the web link to the survey from our email recruitment materials a consent form was presented on the redcap landing page the participants were required to read the form and consent to participate prior to viewing the next page where the survey began all procedures were approved by the institutional review board of the office for the protection of research subjects at a large midwestern university study 1 materials and measures video stimuli development to select the sample of robots to include in the survey we conducted an evaluation of existing sars social characteristics and features with hri smes our goal was to select video stimuli that represented sars that had a variety of form factors and social capabilitiessuch as the robot expressed emotions the robot communicated with users verbally or with sounds and the robot had a distinct personality we downselected from twelve to six robots by choosing robots that scored low medium and high in social capabilities across two tasks response options assessed the level of agreement 1 strongly disagree to 5 strongly agree for each item each video included the robot completing an example iadl task and a humanrobot interaction 2122 prior to reviewing each robot video participants responded to questions about the perceived sociability and perceived trust of the robot all participants received the robot stimuli and survey questions in the same order survey material after watching each robot video participants responded to a set of likert scale questions about their perceptions of robot sociability and robot trust this cycle was iterated for each of the six robots selected for the study the online questionnaire also included several sets of questions on demographics and the initial perceptions of robot characteristics perception of sociability we measured perceived robot sociability using an 8item questionnaire participants rated their level of agreement with the following statements for each of the six robots i think the robot is a pleasant conversational partner i think the robot is pleasant to interact with i think the robot understands me i think the robot is nice i think the robot is relatable i think the robot is friendly i think the robot is polite i think the robot is sociable response options ranged from 1 strongly disagree to 7 strongly agree the items were adapted from previously validated measures 19 perceived trust we operationalized perceived robot trust using an 8item questionnaire participants rated their level of agreement with the following items for each of the six robots i think i would trust the robot if it gave me advice i think if i would give the robot information it would not abuse this i think the robot is reliable i think i have confidence that the robot guides the task i think the robot is precise i think the robot poses risk to the user i think the robot has integrity i think the robot is trustworthy response options ranged from 1 strongly disagree to 7 strongly agree the items were adapted from previously validated measures 19 in addition similar measures have been recently utilized and validated in a related context 23 original version adapted version i would trust the robot if it gave me advice 19 i think i would trust the robot if it gave me advice if i would give the robot information it would not abuse this 19 i think if i would give the robot information it would not abuse this i find the robot reliable 22 i think the robot is reliable it gave me confidence that the robot guides my therapy 24 i think i have confidence that the robot guides the task demographics participants were asked demographic questions including their age gender household income race and level of education study procedure a link to the survey was provided via emails and flyers during recruitment once a participant entered the link they were led to the survey the initial page of the survey was the consent form once consented into the study the first few questions asked the participants their gender date of birth and if they could speak english fluently after completion of the initial background questions the first sar was displayed followed by three questions asking about the participants initial perceptions of that sar participants then watched a video of the same sar performing either delivery or a medication management task after completing the questions for all six sars participants completed a questionnaire that included questions about primary language for communication education marital status racial groups housing information household income employment and disability benefits participants were then able to choose whether they would be willing to provide identifiable information for raffle compensation if the participant agreed they provided their name address and phone number study 1 analytical procedures for the initial analysis we performed descriptive statistical procedures to assess the sample characteristics and to evaluate measures of central tendency for our key variables of interest in addition we performed a simple bivariate pearsons correlation analysis and scatterplot data visualization to assess the primary relationship between sociability and trust study 1 results study 1 relationship between sociability and trust our initial bivariate pearsons correlation results indicated a strong positive linear association between robot sociability and trust in addition robot sociability was associated with almost 60 of the variance in robot trust these findings clearly show that on average robots that were perceived as more sociable were likely to be rated as more trustworthy a link to the survey was provided via emails and flyers during recruitment once a participant entered the link they were led to the survey the initial page of the survey was the consent form once consented into the study the first few questions asked the participants their gender date of birth and if they could speak english fluently after completion of the initial background questions the first sar was displayed followed by three questions asking about the participants initial perceptions of that sar participants then watched a video of the same sar performing either delivery or a medication management task after completing the questions for all six sars participants completed a questionnaire that included questions about primary language for communication education marital status racial groups housing information household income employment and disability benefits participants were then able to choose whether they would be willing to provide identifiable information for raffle compensation if the participant agreed they provided their name address and phone number study 1 analytical procedures for the initial analysis we performed descriptive statistical procedures to assess the sample characteristics and to evaluate measures of central tendency for our key variables of interest in addition we performed a simple bivariate pearsons correlation analysis and scatterplot data visualization to assess the primary relationship between sociability and trust study 1 results study 1 relationship between sociability and trust our initial bivariate pearsons correlation results indicated a strong positive linear association between robot sociability and trust in addition robot sociability was associated with almost 60 of the variance in robot trust these findings clearly show that on average robots that were perceived as more sociable were likely to be rated as more trustworthy study 1 discussion the quantitative assessment strongly supported the notion that perceived sociability and robot trust are positively associated which was consistent with previous qualitative research on hri trust by older adults 8 these initial findings provide evidence for the potential influence sociability may have on hri trust further investigation into how to design robots to be appropriately sociable for a given usecasecontext is required to calibrate hri trust for specific robot form factors however this study was not without limitations specifically we only exposed the participants to the robot videos in one order which could have positively biased results we thus conducted a replication study to reduce this bias and to evaluate the sociabilitytrust relationship in an independent sample of older adults in study 2 we incorporated a counterbalanced study design such that half of the participants were randomly selected to view the robot demonstration videos from high robotics 2023 12 162 7 of 13 social characteristics to low whereas the other half were shown the robots in the reverse order to minimize potential ordereffects in addition we revised our sampling procedures to broaden the participant characteristics study 2 51 method recruitment and sample characteristics the study 2 methodology was generally similar to that used in study 1 while addressing the limitations described to improve rigor for the second study we wanted to achieve more consistency on who our participants were by constraining participation to living in illinois we kept our participant age requirement set from 65 to 85 to recruit participants we engaged community groups across the state university news outlets and email listservs participants had a mean age of 72 years old see table 4 for more details as in study 1 redcap was used for data collection and included the consent form an age and zip code check and general demographic questions and then the participants were introduced to the socially assistive robot videos they were then asked perceived sociability questionnaires and perceived trust questionnaires for each robot study 2 materials and measures video stimuli development we revised the video stimuli to show less commercialized videos and less humanrobot interaction to highlight the sociability of the robot itself our first enhancement was to ensure that the sampled robots had similar capabilities for manipulation and mobility in addition we changed the activities the robots were completing to delivery and cleaning to more appropriately match the robots actual capabilities we then conducted similar sme testing with 13 robots to evaluate the robots social capabilities to make sure there was a stratification between the robots the robots selected are shown in figure 3 video stimuli development we revised the video stimuli to show less commercialized videos and less humanrobot interaction to highlight the sociability of the robot itself our first enhancement was to ensure that the sampled robots had similar capabilities for manipulation and mobility in addition we changed the activities the robots were completing to delivery and cleaning to more appropriately match the robots actual capabilities we then conducted similar sme testing with 13 robots to evaluate the robots social capabilities to make sure there was a stratification between the robots the robots selected are shown in figure 3 survey updates the online questionnaire was slightly updated from study 1 all other materials not listed below remained the same to update and refine the survey we added counterbracing to the robot stimuli as well as the presentation order in survey updates the online questionnaire was slightly updated from study 1 all other materials not listed below remained the same to update and refine the survey we added counterbracing to the robot stimuli as well as the presentation order in addition we added a question in the beginning asking if they felt robots could be used in the future to support older adults and included four more questions about perceptions of sociability for each robot study 2 survey in our second online survey we again showed participants robot videos followed by a series of questions about the stimuli immediately following each video participants responded to questionnaires to rate their perceptions of that robots sociability and trust we used the same eight statements about trust and sociability as in study 1 with some minor adjustmentsmainly to convert the tense from past tense to future tense given that participants did not have physical interactions with each robot additional details about each measure are described below perceived trust we operationalized perceived robot trust with an 8item questionnaire participants rated their level of agreement with the following statements for each of the six robots in study 2 i think i would trust the robot if it gave me advice i think the robot would be reliable i think if i gave the robot personal information it would not misuse it i think the robot would be able to guide me through tasks i think the robot would be precise i think the robot would be safe for a person to use i think the robot would have integrity i think the robot would be trustworthy response options ranged from 1 strongly disagree to 7 strongly agree perception of sociability we measured perceived robot sociability using an 8item questionnaire participants rated their level of agreement with the following statements for each of the six robots in study 2 i think the robot would be a good conversational partner i think the robot would be pleasant to interact with i think the robot would understand me i think the robot would be nice i think the robot would be relatable i think the robot would be friendly i think the robot would be polite i think the robot would be sociable response options ranged from 1 strongly disagree to 7 strongly agree data analyses procedures like study 1 we performed a simple bivariate pearsons correlation analysis and scatterplot data visualization in addition to replicating study 1 we conducted additional analyses with the new sample of data by performing multivariate linear regression analysis as well as additional descriptive statistics for the regression analysis we computed averaged composite measures for sociability and trust to assess the overall association across the entire sample of robots study 2 results study 2 descriptive statistics the tables below display the descriptive statistics for robot sociability and trust for each robot relay and hollie were toprated for sociability and trust and careobot and pr2 were ranked in the middle while stretch and tiago were consistently rated as the least sociable and least trustworthy robots note response options ranged from 1 strongly disagree to 7 strongly agree n 43 study 2 relationship between sociability and trust consistent with study 1 we observed a strong positive bivariate correlation between sociability and trust robot sociability was associated with approximately 63 of the variance in robot trust study 2 relationship between sociability and trust consistent with study 1 we observed a strong positive bivariate correlation between sociability and trust robot sociability was associated with approximately 63 of the variance in robot trust study 2 full regression model results we performed a multivariate regression analysis with overall perceived trust as the dependent variable and perceived robot sociability as the main independent variable in addition we controlled demographic factors in the model our multivariate regression results suggested that robot sociability was positively associated with robot trust net of all controls the full regression model was associated with approximately 63 of the variance in robot trust study 2 full regression model results we performed a multivariate regression analysis with overall perceived trust as the dependent variable and perceived robot sociability as the main independent variable in addition we controlled demographic factors in the model our multivariate regression results suggested that robot sociability was positively associated with robot trust net of all controls the full regression model was associated with approximately 63 of the variance in robot trust study 2 discussion our regression analysis replicated the positive bivariate correlation findings in study 1 between sociability and trust with a different sample of participants and robots on average when a robot was perceived as more sociable it was also rated with a higher level of trust this could suggest that the relationship between perceived sociability and trust is robust in addition to the directionality of the association key test statistics for each analysis were similar across both studies however future work could benefit from assessing these relationships with a larger and more diverse sample of older adult participants general discussion and future work overall the results of our two studies have implications for the design and implementation of socially assistive robots to support daily activities for older adults trust is a crucial factor in determining the acceptance and use of potentially supportive sars by designing sars that are perceived as sociable and friendly developers can help establish trust and increase the likelihood of successful adoption and sustained use by older adults our findings contribute to this domain by providing novel quantitative evidence for the positive association between sar sociability and trust among older adults though the studies utilized different samples of participants and sarsrobot capabilities and form factors we found that older adults consistently reported higher trust for robots they perceived as more sociable in simple terms this means that regardless of form factor sars should be designed to interact and communicate with older adults in a friendly manner to foster the development of trust and potential longterm acceptance to ensure sar designs meet older adults needs future research could further explore the specific features and characteristics of sars that contribute to perceived sociability during colocated interactions with sars in addition longitudinal studies could examine the longterm effects of sar use on trust as well as the potential benefits and challenges of incorporating sars into older adults daily lives effective communication of the robots intentions and behaviors is essential to ensure successful coordination and interaction with humans and other smart technologies in the home 25 to do so we recommend that future work incorporates theorydriven approachessuch as the principles of the uncertainty reduction theory 18 which may guide developers in creating humanrobot interfaces that proactively address older adults uncertainties about sars capabilities and behaviors likewise leveraging related frameworks such as the similarityattraction paradigm 17 could help robot designers to integrate familiar features or configurablecalibrated attributes that resonate more deeply with the elderly thereby fostering trust and acceptance this blend of addressing both cognitive uncertainties and emotional connections could be the key to unlocking the potential of sars in older adults daily routines in addition to these suggestions we encourage researchers to consider other theories as well given a multitude of frameworks could help lead to greater understanding in the hri and aging domainwhich is currently lacking in theorydriven approaches sars have tremendous potential to support older adults understanding the social characteristics that relate to trust can lead to the design of robots that are more likely to be accepted by older adults such acceptance could lead to an enhanced quality of life however it is important to consider the potential risks of overtrusting and overrelying on sars once they are accepted overreliance on the capabilities of a robotic system can lead to adverse and dangerous outcomes especially in the context of aging in places where older adults may have limited physical or cognitive abilities to intervene in case of a malfunction or misuse therefore usercentered design and participatory design approaches are encouraged to calibrate robotic systems sociability and communication behaviors for given usecases and specific user needs and capabilities 26 future research will need to identify the specific features and characteristics of highly sociablefriendly sars that may contribute to overtrust and overreliance and the potential negative impacts associated with it such as a lack of vigilance conclusions our study lays a foundation for advancing the concept of robot sociability in the field of socially assistive robots to enhance the lives of older adults sars that can build trust with their users have the potential to combat feelings of isolation and loneliness enhancing wellbeing for older adults living independently in addition sars may assist in physical tasks supporting continued independence and reducing caregiver burden however for sars to be trusted and accepted our study strongly suggests that robots must be perceived as benevolentsociable by older adults the personalized usercentered approach optimizing for sociability could potentially lead to better health outcomes by improving medication adherence supporting consistent exercise and enabling timely response to health emergencies nonetheless it is crucial data availability statement deidentified data and analytical syntax can be made available upon request to avoid overreliance and ensure that the design incorporates failsafe mechanisms and ethical considerations building sociable and trustworthy sars while respecting older adults autonomy and providing adequate safeguards will optimize the balance between the benefits of technological support and the potential risks associated with its misuse or malfunction such research insights underscore the importance of continuous learning and adaptation in the design and deployment of sars to deliver meaningful and safe interactions that respect older adults needs capabilities and preferences funding this research received no externally funding

older individuals prefer to maintain their autonomy while maintaining social connection and engagement with their family peers and community though individuals can encounter barriers to these goals socially assistive robots sars hold the potential for promoting aging in place and independence such domestic robots must be trusted easy to use and capable of behaving within the scope of accepted social norms for successful adoption to scale we investigated perceived associations between robot sociability and trust in domestic robot support for instrumental activities of daily living iadls in our multistudy approach we collected responses from adults aged 65 years and older using two separate online surveys study 1 n 51 study 2 n 43 we assessed the relationship between perceived robot sociability and robot trust our results consistently demonstrated a strong positive relationship between perceived robot sociability and robot trust for iadl tasks these data have design implications for promoting robot trust and acceptance of sars for use in the home by older adults

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i introduction bangladesh is a highly populated developing country with a population of more than 160 million people and its economy is heavily reliant on agriculture and allied industries poultry a subsector of livestock is an important aspect of bangladeshs agricultural farming system for ensuring sustained protein intake for the population although raising poultry birds is primarily a subsistence industry in bangladesh it is critical to the national economy in terms of creating job opportunities and boosting peoples nutritional levels over 85 million people in bangladesh are directly or indirectly working in this industry which is regarded as the second significant source of employment poultry accounts for 37 of the countrys total meat production and 2227 of the animal protein supply and forms a substantial fraction of the livestock sectors 14 contribution to the countrys gdp in most developing countries livestock raising plays valuable roles in human food and nutrition security livelihood improvement gender mainstreaming and poverty alleviation livestock production particularly poultry farming contributes greatly to peoples wellbeing at the household and national levels according to an fao survey done in 2002 almost 70 of the worlds rural poor people rely on livestock as a source of income or a source of subsistence backyard poultry farming is an essential aspect of rural poultry production in developing nations women are generally involved in this sort of poultry farming however most of them are subsistence in character and indigenous breeds rural women in bangladesh are still disadvantaged and have limited access to incomegenerating activities owing to sociocultural constraints nonetheless they support their families by raising local poultry varieties such as chicken duck and pigeon women in bangladesh contribute not just to their households by assuring sustainable meat consumption but also to the national level in a larger sense by securing national demand for animal protein however their impact was disregarded in scholarly research few studies have been undertaken to enclose their contribution to their families livelihood islam et al showed that greater female engagement in broiler farming might result in considerable development and significantly improved output performance in times of financial hardship disadvantaged women can turn to commercial broiler farming according to chowdhury and chowdhury chakma and ruba assert that womens involvement in agricultural pursuits improves socioeconomic conditions by enhancing food security status family wellbeing and employment opportunities a critical analysis of womens entrepreneurship in bangladesh through poultry farming by begum et al reveals that women face a number of technical social financial and marketing barriers in the industry these issues must be resolved right away previous research has shown that various studies have been undertaken in terms of womens participation in poultry farming in bangladesh but little emphasis has been placed on indigenous poultry farming to enhance the livelihood of rural women in bangladesh as a result the purpose of this research is to analyze the impact of indigenous poultry farming on the livelihoods of rural women in bangladesh this study will assist policymakers and academics in gaining an understanding of womens contributions to their families through indigenous poultry farming at the household level the next part will go over the studys methodologies and materials findings conclusions and recommendations ii materials and methods a study area the area in which the survey will be performed is determined by the specific goal of the survey and the respondents potential cooperation due to the availability of women farmers the current study was undertaken in two places in bangladesh sylhet and mymensingh in northeastern bangladesh sylhet boasts a subtropical climate and lush highland scenery the area has a population of about 5 million people and is one of bangladeshs major cities after dhaka chittagong and khulna the area is geologically complicated with various sacrificial geomorphology and high topography of the pliomiocene age mymensingh covers 436348 square kilometers and is situated between 24°15 and 25°12 north latitudes and 90°04 and 90°49 east longitudes it is bordered on the north by the garo hills and the indian state of meghalaya on the south by the gazipur district on the east by the netrokona and kishoreganj districts and on the west by the sherpur jamalpur and tangail districts b sampling and data collection procedure a full enumeration necessitates data collection from every segment of the population making the survey both expensive and timeintensive the current research was based on a household sample survey that may plausibly reflect the total population due to a lack of time and funds a total of 60 respondents were interviewed employing convenient sampling techniques a closedended questionnaire was developed prior to gathering sample data following the pilot survey required question modifications were made and data was collected from march to april 2022 c analytical techniques descriptive statistics are concise descriptive coefficients that describe a particular data set which might represent the complete population or a sample of a population the data was analysed using descriptive statistics this study investigated the influence of poultry farming on the livelihoods of women farmers because of the simplicity descriptive statistics such as mean median were generated for several livelihood factors iii results and discussion a sociodemographic status of the respondents in this study respondents ages were categorized into three groups as shown in table i according to the data respondents aged 31 to 45 years old made up 55 of the total while the young made up 30 only 15 of those polled were beyond the age of 65 as a result the group of middleaged people was the most populous education is important for all types of inhabitants in a country the process of assisting learning or the acquisition of information skills values morals beliefs habits and personal growth is known as education it has a significant impact on all types of inhabitants in a country to analyze the respondents educational levels they were separated into five groups according to table i 15 of respondents had finished secondary school respondents from various categories such as those who can only sign those who have finished elementary school and those who have finished secondary education made up 1667 3167 and 833 of the total respectively a family or home was described as a group of people who lived together ate from the same kitchen and were ruled by one person as shown in table i 3667 of respondents had a small family other groupings such as medium and big families accounted for 35 and 2833 of respondents respectively the data on respondents land ownership indicated that most respondents held small property followed by medium land in the research region iv impact of indigenous poultry farming table ii shows that about half of respondents said their health status had improved onethird said it had not changed and 1167 said it had decreased the results also revealed that 6667 of total respondents responded to better education and 4667 responded to decisionmaking participation with poultry farming respectively at the same time 20 and 4833 of respondents said that their education and decisionmaking skills had not changed respectively table ii makes it obvious that just onefourth of respondents said their leased or mortgaged land had risen while 60 said it had remained steady and only 15 said it had declined it shows that 6167 of all respondents indicated their monthly income had grown over the survey period compared to roughly 2167 who said it had remained the same and 1667 who said it had declined it is clear from the analysis that about 5833 and 25 of respondents reported a rise in their cash on hand and bank deposit while 3333 and 5167 said their position was steady and just 833 and 2333 of respondents respectively stated their position had declined 4833 of respondents were in favour of growing their savings compared to 2833 who said it remained the same and 2333 who said it had decreased it also indicates that approximately 70 of all respondents believed the value of their poultry bird assets had grown while just 20 said it had remained steady and 10 believed it had decreased table ii also revealed that just 5 of respondents stated their assets had fallen while roughly 5833 of respondents doi 24018ejdevelop202335303 vol 3 issue 5 september 2023 51 said their situation had remained similar and 3667 of respondents said their livestock holdings had increased the data in table ii also reveals that around 5333 of respondents claimed their sanitation status had improved while 40 said it had remained the same and 667 said it had become worse table ii also showed that over 75 of respondents said their television viewing had increased while 2167 said their perceptions had not changed and 333 said their viewing had decreased v conclusion bangladesh is a developing country and heavily reliant on agriculture as a means of livelihood eggs and poultry meat are good sources of protein in terms of nutrition in bangladesh for the rural community for rural women seeking to generate cash keeping family poultry might be a good opportunity and almost every household in rural areas is engaged in indigenous poultry farming family poultry farming can assist in achieving socioeconomic development in the rural economy since many rural women dont have access to incomegenerating activities due to social and cultural barriers because poor rural women have considerable time to raise home poultry there is sufficient space for the expansion of family poultry farming in bangladesh it would be beneficial for generating cash empowering women and enhancing the farm familys nutrition the results showed that indigenous poultry farming contributes significantly to their livelihood in different ways like ensuring regular cash flow increasing savings contributing to education and improving sanitation overall it improved food patterns strengthened female empowerment among poultry farmers and enhanced family health in light of the studys findings it is possible to draw the following conclusions 1 the standard of living for the respondents has significantly improved since they started the poultry farm 2 women might contribute significantly to the socioeconomic development of the family and the country the socioeconomic advancement of the family can be significantly aided by the right environment and facilities being offered 3 the accessibility of poultry farming is a crucial element in involving rural women in endeavours that generate income and advance development

the goal of the current study was to determine how indigenous poultry farming in sylhet and mymensingh districts affected rural womens means of subsistence data were gathered at convenient sampling techniques from sixty respondents who were active in poultry farming with these viewpoints in mind the necessary data was gathered using the survey method and a welldesigned questionnaire descriptive statistics and a sustainable livelihood framework were employed for the data analysis and assessment of the effects of chicken farming results revealed that after starting the chicken farm the respondents assets significantly increased in support of an enhanced standard of living the results showed that raising poultry had a favorable effect on the respondents ability to support themselves indicators of womens social empowerment such as their attitudes toward their childrens education their mobility outside the home and their capacity for involvement and decisionmaking were also found to be significantly positively impacted finally the current study recommends performing additional research of a comparable nature in other regions of the nation in order to make the findings representative

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introduction the recent global increase in chronic noncommunicable conditions such as cardiovascular and metabolic diseases has been a major focus of epidemiological research over the past several decades cardiovascular disease is now the leading cause of death worldwide affecting populations in both developed and developing nations similarly metabolic diseases such as type ii diabetes have increased rapidly throughout the world with over 360 million individuals projected to have diabetes by 2030 cardiovascular and metabolic diseases are closely linked with overweight and obesity which have also increased rapidly in recent years as over 15 billion adults worldwide are currently considered overweight or obese risk factors for cvd and t2d include tobacco use alcohol consumption chronic psychosocial stress and physical inactivity but dietary change associated with increased consumption of energydense highly processed foods is thought to be of prime importance despite progress on understanding this epidemiological transition it has been difficult to empirically link regional social and economic changes to individual behaviours and health outcomes as a result the specific mechanisms responsible for the recent increase in cvd and t2d remain incompletely understood market integration the suite of social and cultural changes that occur with economic development is a key factor affecting individual health outcomes among indigenous groups although debate exists over how best to conceptualize and operationalize mi this process involves the emergence of marketbased systems of exchange and specifically the increased degree of participation in and dependence on markets to obtain food resources the transition from a subsistencebased lifestyle to a market economy influences myriad dimensions of life there is however disagreement about whether mi produces overall negative positive or mixed effects on health in many studies mi has been linked to negative health markers related to cvd and t2d whereas in other studies mi has been linked with improved growth and lower mortality risk particularly for children as a result of increased dietary diversity and access to healthcare further research among groups such as native siberians has identified a positive correlation between continued participation in subsistencebased lifestyles and elevated risks of cvd additional studies have suggested that cultural and economic transitions produce mixed and ambiguous health outcomes which may change over time due to multiple conflicting pathways these inconsistent results underscore the need to clarify the multiple social and economic factors that influence health change among populations experiencing mi and to better understand how regional and global factors influence the experience of mi at the household and individual level a further complication is that adaptation to local environments may shape how different populations experience the health effects of economic and social change for example the main cardiovascular risk factor for native siberians is high blood pressure yet these populations display relatively favourable blood lipid levels this contrasts with the pima of north america and aboriginal australians who appear to be particularly susceptible to insulin resistance and t2d at present the extent to which genetic and lifestyle factors interact to shape regional variation in chronic disease patterns remains unclear yet links between health risk and metabolic patterns suggests that there may be an adaptive component to this variation a major challenge facing researchers is to connect specific cultural and lifestyle changes to health outcomes and to explain intraand interpopulation variation in health profiles these findings again highlight the complex interrelated pathwaysincluding genetics behaviour healthcare environmental resources and demographicsby which changes in economic social and cultural systems can impact individual health and lead to significant differences among populations in chronic disease prevalence one final issue related to mi and health is the paucity of research focused on the consequences of dietary and lifestyle change for indigenous south american groups the few studies that do exist document variable effects of greater mi on child growth as well as higher rates of cardiovascular and metabolic risk factors such as obesity and elevated plasma glucose further previous research among native south americans has generally focused on single markers of cardiovascular or metabolic health which gives an incomplete and narrow picture of the health implications of culture change in these populations the present study broadens the literature on these issues by examining mi and a variety of markers of cardiovascular and metabolic health among shuar an indigenous population from amazonian ecuador shuar currently experience a wide range of mi both within and between communities in general however communities in the upano valley have greater access to roads and towns which increases access to wage labour as well as markets for sale and purchase of food in contrast villages east of the cutucu ´mountain range have limited road access and most people in this region remain largely dependent on horticulture fishing and hunting for daily subsistence thus while shuar populations are closely genetically related and share a common recent culture their variation in market access and integration into a market economy provides an excellent opportunity to examine the effects of rapid economic development on individual health the present study has the following three objectives objective one evaluate the health of indigenous ecuadorian shuar to characterize patterns of cardiovascular and metabolic risk we hypothesize that shuar will display relatively favourable cardiovascular and metabolic health profiles based on current clinical guidelines from the us and other industrialized nations this expectation is based on the overall low degree of mi among shuar and their continued reliance on a subsistence lifestyle objective two compare cardiovascular and metabolic health of shuar from the uv and crosscutucu ´ regions we hypothesize that uv shuar will demonstrate less favourable cardiovascular and metabolic health profiles as a result of increased exposure to and engagement with the cultural and economic systems associated with western societies objective three examine how specific factors related to mi including dietary and lifestyle measures are associated with different cardiovascular and metabolic health outcomes we hypothesize that increased consumption of marketbased foods ownership of more consumer goods and residence in a household with modern features indicate greater participation in the market economy and will be associated with poorer cardiovascular and metabolic health materials and methods study populations this study was conducted among the indigenous shuar of lowland amazonian ecuador in the province of moronasantiago first direct contact between shuar and nonshuar was with spaniards in 1549 shuar later expelled the spaniards from their territory in 1599 and permanent trade was not reestablished until the 1890s through the renewed trade system shuar gained access to shotguns and expanded eastward from the uv and paute river drainage across the cutucu ´mountain range which remains the main geographic barrier limiting economic development in the eastern lowlands missionization started in the 1940s but largerscale colonization did not begin until the 1950s with the formation of ficsh in the 1960s to protect shuar interests most households began clustering in centros in response to various political exigencies at present the ecuadorian shuar are a rapidly growing population of 60 000110 000 persons living in 668 communities with very few exceptions shuar living in communities remain a natural fertility population with limited contraceptionuse average age at menarche 13 years first parturition 175 and average lifetime live births among postmenopausal women 84 geographically the uv is characterized by montane neotropical forest while the cc is characterized by forest ranging from montane to lowland floodplain the uv region experiences less rainfall and temperature variation across the year compared to cc for example average temperature in the uv ranges from 16 208c while temperature in the cc region averages between 24 388c although some shuar live fully marketintegrated lifestyles in towns diet within shuar communities remains based primarily on subsistence horticulture each shuar household typically has two or three gardens at different stages of production or a single large garden with intercropping and staggered planting seasons gardens provide the primary source of carbohydrates contributing 65 of dietary calories staple foods include yucca and plantains which are consumed daily other important crops include sweet potato bananas palm maize papaya pineapple and sugar cane hunting was traditionally practiced with blowguns dogs and traps but shotguns have been used for a hundred years in some areas collared peccary continues to be an important source of game as well as paca tapirs armadillos and several monkey species traditional fishing involved two kinds of fish poisons although nets and hookslines are now also used while no direct observational data on hunting and fishing productivity in the uv are currently available ethnographic observations interviews and food frequency data indicate that hunting and fishing near uv communities has declined while these foraging practices particularly fishing remain productive and important subsistence regimes in the cc area in uv communities most shuar now purchase a range of market items and engage in some marketoriented agropastoralism or wage labour for example in a 2005 survey 19 of households in this region sold timber in the past year 30 sold crops of some kind and 38 either owned a cow or raised one owned by another person a few shuar earn salaries as government employees but most wage labour is based on daywork in which both male and female uv shuar participate further most uv shuar currently live within walking distance of roads reside in large communities and have divided land into individuallyowned plots the uv sample in the current study includes rural communities located 45 minutes outside of the town of sucu ´a by paved and dirt road these villages offer water lines coming from freshwater springs electricity for those who can afford it and regular access to small stores and markets in town and the regional centre in contrast the cc communities are located 9 hours by bus and an additional 6 12 hours by motorized canoe from the regional centre individuals in these communities have no direct road access and less reliable travel infrastructure primarily due to frequent landslides and limits on canoe travel during high or very low river stages as a result cc villages lack efficient market access thus subsistence remains based on fishing hunting and horticulture with limited agricultural cattle or timber sales anthropometric measurements anthropometric measures were collected using established procedures one researcher was assigned to collect all of the measurements using a given technique during each field season and attempts were made to use the same researcher across multiple seasons training sessions were conducted prior to each field season to minimize interobserver error stature was recorded to the nearest 10 mm using a field stadiometer body weight was measured to the nearest 01 kg using a tanita bf558 electronic scale three circumferences were recorded stature weight and all body circumferences were determined by a single measurement body fat was estimated according to the sum of four skinfolds using sexand agespecific equations skinfold measurements were repeated 3times without clothing and estimated to the nearest 05 mm with lange skinfold calipers health measures to evaluate cardiovascular health a finger prick with a sterile disposable lancet was used to obtain 35 ml of whole capillary blood which allowed for measurement of total cholesterol hdl cholesterol ldl cholesterol and triglycerides fasting glucose concentration was measured from 15 ml of whole capillary blood typically obtained from the same finger prick both samples were assessed using a cardiochek pa clinical system and pts panels this instrument provides immediate measurements of glucose and lipid values and meets us standard clinical guidelines for accuracy and precision all measures were obtained from participants after a 12hour fast the cardiochek pa classifies individuals with triglycerides below 50 mgdl as low with no numeric value provided in these cases ldl cholesterol cannot be calculated since ldl values are estimated using the friedewald equation as recommended by the us national cholesterol education program desirable lipid levels are tc 240 mgdl hdl 40 mgdl ldl 160 mgdl and triglycerides 150 mgdl fasting glucose levels were classified based on american diabetes association guidelines as normal impaired fasting glucose and diabetes arterial blood pressure was measured as systolic blood pressure over diastolic blood pressure all participants sat in a relaxed position while a trained observer collected a single measurement with an automatic lifesource ua767 plus blood pressure monitor following guidelines from kaplan sbp at or above 140 mmhg andor dbp at or above 90 mmhg were classified as hypertensive values between 12080 and 13989 mmhg were prehypertensive and levels at or below 12080 mmhg were normotensive lifestyle factors structured interviews were conducted to collect basic demographic and lifestyle information all instruments were administered in spanish which most shuar speak fluently a bilingual assistant translated for those participants not fluent in spanish all participants were asked a series of questions from a modified version of the material style of life index the sol is simply a list of market items and sol scores are the sum of the number of index items a household owns for this study we constructed two scales referred to as traditional style of life and marketintegrated style of life to assess not only market good ownership but ownership of goods involved in traditional subsistence activities the selection of items in the shuar sol was based on several years of ethnographic observations by one author and initial interviews conducted with extensive lists of items that were shortened after pilot testing items were selected that were not so common as to lack variation between households but not so rare as to be unique to individual households we also selected items representing a continuum of investment in the traditional economy or involvement in market trade for example chainsaws require a large initial investment and the continual purchase of gasoline the final tsol scale contained six items reflecting investment in a foraging lifestyle while the msol scale included 12 items reflecting investment in a market economy individual scores were calculated as the fraction of list items owned six household measures were also incorporated as indices of household permanence access to infrastructure market participation and pathogen risk these included in order of increasing market integration floor wall latrine type water source electricity and number of rooms in house a household style of life value for each individual was computed based on a summation of the scores shown in general high tsol values indicate greater participation in subsistence activities while high msol and hsol values indicate greater participation in market activities however it is important to note that although across households the msol and hsol are positively correlated with each other and negatively correlated with the tsol individual households could be high on all scales low on all or any combination for this reason separate analyses based on the tsol msol and hsol scores were conducted dietary factors in accordance with standard field techniques used to measure dietary composition a food frequency questionnaire was administered via structured interviews to collect information about common food items and typical fooduse patterns among shuar the ffq was designed to efficiently assess variation in diet between individuals rather than to provide exact caloric or nutritional estimates during pilot work 24hour food recalls were collected from several dozen individuals foods listed in these recalls andor known from extensive ethnographic work were combined into a food frequency questionnaire which included 19 common food items or food categories participants were asked how often a specific category or type of food was consumed and could respond with reference to the unit of time preferred to account for seasonality individuals were asked whether their patterns were typical for the year or if their consumption pattern varied seasonally or based on occasional cash flow responses were then standardized as consumption frequency per year statistical procedures reduction of dietary factors due to the large number of dietary variables ffq data were reduced to a few manageable factors capturing the primary dimensions of variation first the internal consistency of the ffq was calculated to determine the degree of intercorrelation between the food items which is a standard psychometric procedure used prior to a principal components analysis as indicated by cronbachs coefficient alpha the internal consistency of the ffq was relatively high thus all 19 items were retained for assessment and were evaluated with principal components analysis in order to examine the patterns of correlations between food items and to reduce dietary variables into manageable factors for multivariate statistical tests further the 19 items in the ffq were rotated using an oblique promax procedure to maximize the factor loadings and improve the interpretation of results based on the scree test five components with eigenvalues greater than one were identified table i presents the factor structure of the rotated solution which cumulatively accounted for 491 of the item variance market products such as rice bread and soda loaded positively on the first component which included seven items and was classified as the market food component local plant greens fruits vegetableslegumes and eggs loaded onto the second component which was identified as the fruits vegetables and eggs component the third component included chicken and two items related to hunted game and was described as the hunted game and chicken component two items fishshellfish and beef loaded onto the fourth component which was defined as the fish and beef component market food products high in refined carbohydrates such as pasta clustered onto the fifth component while local carbohydratebased products such as potatoes yucca and plantains were negatively associated with this dimension this construct was named the market carbohydrates component for all subsequent analyses the five food components were used as indicators of dietary patterns positive ffq values indicated greater consumption of a specific food category whereas negative ffq values specified lower consumption all ffq analyses were conducted with sexes combined hypothesis testing prior to analysis all variables were examined for accuracy of meeting standard parametric assumptions some variables were slightly skewed so tests were conducted with both log 10 transformed and nontransformed data using transformed values did not significantly change results thus tests with nontransformed values are reported since they are more interpretable we excluded one 32yearold woman from a cc community who had a fasting glucose level of 299 and was identified as a statistical outlier given her age and the extreme nature of her health status we suspect her condition was either untreated type i diabetes or perhaps a secondary complication of an undiagnosed medical ailment objective one descriptive statistics were calculated to characterize patterns of cardiovascular and metabolic health among shuar independentsamples ttests were used to evaluate differences between males and females from the same subject population for age the seven health markers and anthropometrics objective two twoway analysis of covariance tests with age and bmi as covariates were conducted to compare the cardiovascular and metabolic health of male and female shuar from the uv and cc regions this procedure was used to examine the main effects and interactions of sex and population while controlling for the effects of age and bmi on the cardiovascular and metabolic measures to verify that the relationship between the covariates and dependent variables did not differ significantly as a function of sex and population the homogeneityofslopes assumption was evaluated six of the seven health markers did not violate this assumption for triglycerides bmi as a covariate significantly interacted with the main effect of sex indicating that bmi varied between males and females and could not be used as a covariate in the ancova models the following results for triglycerides were evaluated in consideration of this homogeneityofslopes violation all means and standard errors are reported after adjusting for the covariates for ancova analyses with a significant interaction between sex and population followup simple main effect tests were conducted to examine the differences in means among uv and cc males and females objective two comparing health measures between crosscutucu ´shuar and upano valley shuar a series of twoway analysis of covariance tests with age and bmi as covariates were conducted to compare the cardiovascular and metabolic health of male and female shuar from the uv and cc regions the significant test results for the lipid measures and the metabolic and blood pressure markers are presented in tables iii andiv respectively the ancova for tc identified a significant difference between males and females as well as between uv multiple regression tests were used to estimate the relative contribution of dietary and lifestyle factors to variation in cardiovascular and metabolic health the regression model for each health indicator included age sex bmi the five food components and the three sol scales these results are presented in tables vi andvii the full regression model accounted for a considerable amount of variation in tc hdl ldl triglycerides sbp and dbp the proportion of variance explained in the regression model with glucose as the dependent variable was not statistically significant but did show a positive trend age and sex were significant predictors of tc hdl ldl and sbp bmi was a significant predictor of triglycerides and dbp for the ldl cholesterol model two food factors hunted game and chicken and market carbohydrates were significant predictors in the glucose regression model the fruits vegetables and eggs food factor was a significant predictor indicating that greater consumption of fruits vegetables and eggs is associated with lower glucose levels discussion objective one cardiovascular and metabolic health profiles among shuar as expected the present study demonstrated that indigenous shuar males and females have relatively favourable cardiovascular and metabolic health profiles according to established international guidelines thus while villageliving shuar are experiencing varying degrees of mi across their territory the population in general maintains a cardiovascular and metabolic profile that contrasts markedly with most industrialized nations nevertheless our findings document considerable variation in cardiovascular health patterns within and between uvand cc regions in part this reflects the focus on multiple markers of chronic disease risk however it also suggests a relationship between mi and health that is heterogeneous and shaped by exposure to a range of factors associated with mi for example mean tc levels for males and females from the uvand cc regions were in the optimal range yet sbp levels for uv males were elevated the higher sbp levels of uv males may be a consequence of increased exposure to the chronic psychosocial stressors associated with involvement in a market economy including economic competition and the emergence of new markers of social status commonly linked to western material goods and lifestyles however this issue remains speculative until other biomarker data on adult psychosocial stress profiles are collected from a larger sample of adults than currently available this study also revealed important differences in cardiovascular and metabolic health between shuar males and females for example females had significantly higher levels of tc hdl ldl and glucose than males these results may reflect differences between shuar males and females in their responses to dietary and lifestyle change suggesting that there may be sexspecific physiological responses to the process of mi additional details about this finding are discussed below objective two comparing health measures between crosscutucu ´shuar and upano valley shuar our results partially support the second hypothesis that uv shuar would display less favourable cardiovascular and metabolic health profiles than cc shuar for example shuar from the uv had higher tc levels than cc shuar however this finding appears to be the result of higher hdl cholesterol levels and therefore is not necessarily consistent with poorer cardiovascular health further contrary to our prediction shuar from cc had higher dbp levels overall this study shows many similarities between the two groups and contrasts with a number of previous studies that document rapid declines in cardiovascular and metabolic health with sociocultural and economic transitions figure 3 glucose means for male and female shuar from the upano river valley and crosscutucu ŕegions figure 2 ldl means for male and female shuar from the upano river valley and crosscutucu ŕegions there may be several reasons for a less pronounced decline in cardiovascular and metabolic health among shuar in this sample first ethnographic observations and interview data suggest that the consumption of highly processed starches or fatty foods often associated with chronic diseases such as diabetes and obesity remain limited among villagedwelling shuar specifically our ffq data demonstrates that the dietary staples in these communities remain a few traditional crops regardless of level of mi plantains and bananas in particular may be protective against adverse cardiovascular health outcomes due to potassium content second major changes in mi among shuar are relatively recent thus the cumulative duration of exposure to cardiovascular and metabolic risks is likely lower than many other populations experiencing lifestyle change further parasitism by helminth may help maintain normal blood lipid and bp levels indeed helminth infections appear endemic even in the uv an alternative explanation is that our measures of mi may be limited in their ability to capture the critical components of mi that affect cardiovascular and metabolic health future work is needed to develop a more nuanced understanding of the relationship between culture change and cardiovascular and metabolic health one difficulty of interpreting population variation in the effects of mi is the potential for sex differences in health markers an important finding in the present study is that shuar females from the uv have significantly higher levels of ldl cholesterol compared to cc females as well as uv males it is unclear what is responsible for this pattern but it appears that shuar females in marketintegrated communities are more susceptible to some of the economic and cultural changes in this region perhaps as a result of shifting dietary and activity patterns although speculative our work among a uv community has demonstrated significantly lower activity levels among women compared to men suggesting that decreasing physical activity among shuar women may contribute to the worsening lipid profile further uv shuar females are progressively acquiring wage labour jobs in town thereby increasing their exposure to processed high fat marketfood items such as cookies and sweets which may potentially lead to elevated ldl cholesterol levels future research is needed to clarify these relationships the present study demonstrates that mi does not have a simple homogenous negative effect on health although many studies have found mi to be associated with rapid deterioration of cardiovascular and metabolic health our results are similar to several other studies in their findings of mixed health outcomes whether mi has a positive or negative effect on health instead depends on local conditions and factors such as the character intensity and duration of mi the existing health and diet of the and have houses with modern features tend to eat more markettype foods refined carbohydrates and beef conversely shuar who consume fewer market food items and own more traditional products maintain a subsistence lifestyle with limited consumer goods this study demonstrated partial support of our third hypothesis which proposed that the consumption of marketbased foods and the ownership of consumer goods associated with greater mi would be linked to adverse cardiovascular and metabolic health markers for example greater consumption of chicken is associated with higher ldl levels which suggests that shuar may be adopting dietary practices that afford greater access to animalbased products that are high in protein but also high in unhealthy fats contrary to our expectation higher hdl levels were also associated with degree of household mi while speculative this finding may be a result of increased dietary diversity among households with more market resources for example rather than relying on a few staple carbohydrate products households with greater mi may have more consistent opportunities to acquire a variety of fruits and vegetables sold in markets as well as proteinrich foods thereby influencing their hdl levels study limitations this study has several limitations first participant sample sizes were uneven between the uv and cc groups which restricted our ability to conduct separate multivariate analyses for the shuar groups particularly separate principal component analyses of the food frequency data this issue limited our capacity to examine how the relationships between dietary factors lifestyle measures and cardiovascular and metabolic health markers varied between shuar in different environments additional cardiovascular and metabolic health data were collected from cc shuar during summer 2012 which will be used in future analyses to address these issues second the present study used a food frequency questionnaire to assess dietary patterns but as applied in this population it does not provide reliable quantitative information on intake of energy or nutrients this limits our ability to link the intake of particular food items with health measures future research will include 24hour diet recall measures in order to capture additional quantitative information about the shuar diet third while standard ethnographic and analytical procedures were implemented to capture lifestyle variations among shuar the authors recognize that the sol measures used in the present study provide an imperfect and limited representation of mi however despite these concerns the present study attempts to identify culturallygrounded indices of material lifestyle differences among shuar in our future research we plan to refine our current techniques as well as add supplemental measures of mi to enrich our understanding of the cultural and economic changes experienced by shuar fourth this study primarily focused on shuar from small rural communities but did not include shuar who have grown up or lived in towns or cities such as sucu ´a for substantial portions of their lives shuar from towns may experience more pronounced dietary and lifestyle changes associated with even greater levels of mi along with increased risks of cvd finally the present study evaluated the links between culture change and health using crosssectional data but this approach is limited in its ability to make causal links and to detect trends over time our ongoing research is in the process of addressing all of these issues conclusions previous studies suggest that there are several pathways by which cultural and economic changes impact individual health including behaviour healthcare and psychosocial stress yet researchers disagree on whether the transitions associated with mi produce negative positive or mixed effects on the health of individuals experiencing these changes the present study provides evidence of variability in health diet and lifestyle factors among shuar an indigenous population from the lowland regions of amazonian ecuador who are experiencing rapid mi this research also paints a complex picture of the effects of mi on cardiovascular and metabolic health and suggests that mi does not necessarily lead to universally negative health changes in chronic disease by collecting and evaluating data on multiple levels including the individual the household the community and the region this study is a first step in documenting the multifaceted and dynamic processes of mi in southeastern ecuador thereby developing a more complete understanding of health in the context of cultural and economic change

background market integration mi the suite of social and cultural changes that occur with economic development has been associated with negative health outcomes such as cardiovascular disease however key questions remain about how this transition manifests at the local level aim the present paper investigates the effects of mi on health among shuar an indigenous lowland ecuadorian population with the goal of better understanding the mechanisms responsible for this health transition subjects and methods this study examines associations between measures of mi and several dimensions of cardiovascular and metabolic health fasting glucose lipids ldl hdl and total cholesterol triglycerides and blood pressure among 348 adults results overall shuar males and females have relatively favourable cardiovascular and metabolic health shuar who live closer to town have higher total p 0001 and hdl cholesterol p 0001 while shuar in more remote regions have higher diastolic blood pressure p ¼ 0007 hdl cholesterol is positively associated with consumption of market foods r ¼ 0140 p ¼ 0045 and ownership of consumer products r ¼ 0184 p ¼ 0029 conclusions this study provides evidence that mi among shuar is not a uniformly negative process but instead produces complex cardiovascular and metabolic health outcomes

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introduction the covid19 pandemic ushered in unprecedented change for organizations globally leaders had to design fitforpurpose operating models which included new ways of doing things new roles and new ways of leading self and others covid19 was first identified in november 2019 in wuhan the capital of chinas hubei province the disease causes severe acute respiratory illness which was sometimes fatal the disease rapidly spread around the world and no continent escaped the disastrous health consequences and socioeconomic impacts leaders worldwide were forced to design and implement strategies to deal with the pandemic at a very fast pace national lockdowns were instituted globally which compelled people to remain in their homes in an attempt to control the spread of the virus in south africa the economy slowed down job losses increased and other existing socioeconomic challenges were exacerbated as a result of the lockdown regulations during the lockdown period the tools and technology of the fourth industrial revolution were implemented at an accelerated rate to establish a new way of working one of the immediate requirements during the covid19 pandemic was for organizations to ensure continuation of their business through virtual working enabled by technology and reskilling their employees remote workplaces became the new normal which came with its own set of challenges for leadership and leadership identity little is known about how a crisis like the covid19 pandemic affects the way leaders leads and the influence this has on their identities as leaders there is a clear link between identity and leadership which is why in this study we examined how leaders responded to the various workplace challenges presented by the covid19 pandemic and in particular what this meant for their work identities as leaders to do this we made use of role identity theory social identity theory and leader identity theory work identity work identity can be considered a multiidentity multifaceted and multilayered construction of the self gini posited that fundamentally individuals form their identities through the work that that they do walsh and gordon defined work identity as a workbased selfconcept comprised of a combination of organizational occupational and other identities that affects the roles people adopt and the corresponding ways they behave when performing their work popovanowak similarly defined the concept as a multidimensional workbased selfconcept reflecting individuals selfimage that integrates organizational occupational and other identities shaping the roles and behaviors of individuals when they perform work work identity is formed through the personal experiences occupational skills work context work practices and social memberships of an individual it is considered the importance of work for a persons sense of self and how you define yourself through your engagement with various aspects of your work such as your occupation workroles and organization another definition is that a work identity is a socially constructed representation of an individuals unique selfperception of hisher own interactions within the employment environment caza et al 2018 found that work identity causes individuals to perform their work in ways that reflect how they think and feel about their creativity belief systems and personal relationships with others social identity theory social identity theory describes how selves are personally contextually and socially derived an individuals selfconcept is partly derived from the groups of which he or she is a part which could include the departments and organizations in which they work and their professional affiliations in this process the selfconcept becomes depersonalized organizations are social entities comprised of groups of people who collaborate and interact to perform work and these groups of individuals develop and sustain socially derived identities the identity of the group has a significant influence on the interests and motivations of group members membership of a group strengthens ones position as a leader and a professional social identity allows individuals within groups to experience connection in the pandemic it was shown that social identity continuity helped to reduce loneliness amongst employees role identity theory role identity theory seeks to explain the various roles we hold in our lives and that these roles come with prescriptions of how individuals should behave a role identity stems from an individual occupying or possessing a specific role according to walsh and gordon a work identity is a reflection of the claimed central character of employees performing their workrelated roles if individuals have a strong role identity they are more likely to take part in the rolebased behaviors associated with the role thus meeting role expectations according to identity theory role identities are formed as individuals work and interact with others in order to fulfill role expectations one such role is that of leader how a leaders identity is formed at work may also be explained through role theory kwok et al argue that leaders develop leader role identities when they perceive themselves as leaders which influences the extent to which they behave in a leaderlike way this then strengthens others perception of them as leaders which leads to a stronger acceptance of them as their leaders leader identity and leadership identity leader identity is defined as a subcomponent of ones identity that relates to being a leader or how one thinks of oneself as a leader leadership identities are defined as experienced and projected selves or personas that aspire to look like leadership leaders are increasingly compelled to manufacture and project a sound and convincing sense of themselves wanting to be seen as strategists and visionaries leaders are both authors of and objects of identity production this phenomenon is referred to as identity work materials and methods a qualitative approach was used in this study as we sought to understand the perceptions and related actions of leaders in the covid19 pandemic purposive convenience sampling augmented by snowball sampling was used as it enables researchers to select participants who will make a valuable contribution to understanding the problem under study the data were collected using semistructured interviews this method was utilized because it offers flexibility by allowing new topics to emerge for exploration and further discussion additional questions were posed to some participants to probe and obtain additional indepth information while some interviews were conducted in person the majority were conducted virtually using amongst others microsoft teams zoom google meet due to the covid19 pandemic restrictions all interviews were recorded with permission of the participants using the cell phone application voice recorder lite the voice recordings were then transcribed using otterai participation was voluntary and each participant signed an informed consent form anonymity and confidentiality were maintained throughout the research prior to the commencement of data collection ethical clearance was obtained the ethics committee of the department of industrial psychology and people management at the university of johannesburg the sample for this study consisted of a group of eight leaders from various south african and international organizations who led projects business units andor teams during the covid19 pandemic table 1 provides the biographical information of the participants the data were analyzed using thematic analysis which is a method for identifying analyzing and reporting patterns within data and is widely used in qualitative research using an excel spreadsheet the steps proposed by braun and clarke were followed which are as follows familiarization with the data whereby the transcribed data are read and reread several times noting key points generating initial codes and organizing the codes into meaningful groups distinguished using color coding the next phase was to search for themes which involves taking a broader view of the data set different sets of codes were combined to form a theme thereafter the themes were refined or narrowed down by choosing the themes that appeared most in the data set and checking if the themes were aligned to the coded extracts and the entire data set the themes were also refined by looking at the data in a particular code to see if there was a pattern that made sense a further review was done on the entire data set to see if the patterns that had emerged made sense the last phase involved defining and naming the themes each of the themes was then checked and evaluated against the dataset and the research questions findings overall participants related that the pandemic regulations introduced issues such as endless online meetings burnout because of longer working hours impacts on family life negative effects on physical and mental health increased customer needs and supporting teams with issues such as fear of job loss illness and death in the family working from home with limited office space and stress many participants indicated that it was both challenging and enriching to lead themselves and their teams during this time it is clear that the leaders occupied multiple roles during the covid19 pandemic in order to keep up with the change the detailed findings of this study are presented according to five themes namely customer centricity managing performance building effective teams building a digital culture and work identity theme 1 customer centricity the customer centricity theme emerged mainly when the participants were asked what they liked most about their role the leaders in this study mentioned that it was key to understand customer needs so that they could build products and services that would satisfy their customers needs and expectations the codes that emerged under the customer centricity theme were understanding the business understanding customer needs building solutions for customers judgment and risktaking and building great relationships with customers for example with regard to understanding the business participants noted a renewed focus on certain aspects participant 1 said i like the outcomes of this role being able to retain the client understanding the outcomes of the customer research relooking product information and pricing in order to retain clients and achieving customer retention targets for a large insurance company is satisfying statements to support this included i have to meet my customers delivery dates and we used basic technology to help with research to understand why our customers were leaving us many participants indicated the need for building solutions for customers for example in an everchanging environment the organization looks to its leaders to provide the solutions during times of change i must provide strategies and solutions with regard to judgment and risktaking some leaders indicated that in a highly regulated environment such as banking or insurance there is little room for judgment and decisionmaking and that this can be frustrating when it slows down delivery and meeting customer expectations participants indicated that they preferred a work environment where they are empowered to use their judgment in making decisions in a collaborative way provided they do not place the business at risk in support of this participant 1 stated i would make a judgment call and go outside the boundaries as long as it was legal and not putting the business at risk there has to be room for strategic thinking planning and flexibility to allow for nonconventional decisionmaking and i must be able to use judgment in decision making participant 8 stated i like an environment where people are empowered and expectations are clear concerning building great relationships with customers participants indicated that key to business success is the ability to remotely build relationships with customers and partners participant 6 proudly noted i am a trusted business partner while participant 5 said i build great relationships with my client base however some participants indicated that building customer trust was very challenging during lockdown theme 2 managing performance leaders in this study mentioned they had to assume the role of performance manager for their organization their team and for themselves in addition to this they had to also see to the wellbeing of their individual team members according to participant 8 covid has affected peoples mental health it has affected their ability to engage externally it has affected their ability to even engage in the company so now you must pay much more attention to mental health and wellbeing instead of staff performance only participants stated that during the covid19 lockdown they were dealing with staff wellbeing especially mental wellbeing and loss of loved ones general fear and manual processes this led to participants adjusting the way in which they managed staff performance and led during this period this theme is supported by the codes organizational strategy setting clear goals and expectations providing open and honest feedback coaching acknowledging ones team building relationships with the team and trust with regard to organizational strategy participants indicated that they had to get involved in formulating strategy in a collaborative way with internal and external partners this is evidenced by the following extracts i spend an awfully long time coaching rather than leading i play different rolesstrategy coaching implementation alignment my brain had to change six or seven times a day depending on what kind of call i have leaders indicated that setting clear goals and expectations was key in managing their own performance and that of their team and that this aspect became crucial during lockdown when teams had to work virtually participant 2 noted having to get something sorted out to meet targets participant 1 mentioned a focus on outcomes of the role being able to retain the client achieving the targets the participants indicated that in building an effective team providing open and honest feedback to their peers their managers and the people who report to them is crucial in achieving desired outcomes that would ultimately address customer needs and ensure achievement of performance objectives this was made clear through statements such as i must have a positive attitude let go and move on be open and honest have no hidden agenda and provide honest feedback i will confront issues that i believe needs to be changed for the good i will speak my mind and coaching becomes very key in giving realtime feedback the code coaching was mentioned several times by participants during the discussion of team performance this code was mentioned by two participants as the element they enjoyed the most in their job participant 7 had taken on coaching people to be their best in their current role while participant 6 stated i spend an awfully long time coaching rather than leading participant 2 said that she had enjoyed the opportunity to display natural leadership interacting with people giving guidance to others setting the example coaching and mentoring participant 8 indicated i have checkins with the team once a week sometimes impromptu meetings not about work but about their lives i create a platform for people to discuss their issuesmental health dealing with loss of family due to covid19 fear of losing jobs combining home life and work life while working from home etcetera the participants all mentioned the importance of acknowledging ones teams and most of the participants spoke at length about the importance of having a highperforming team and the leaders role in building such teams participants indicated that their ideal work environment was one where everyone understood what they must do and that they do it participant 4 stated what i like most in my role is team involvement and teamwork and added i view myself as one of the guys as a team member i dont enforce my position participant 2 stated what i like most in my role is the opportunity to display natural leadership ie being a leader without necessarily having a leadership title interacting with people giving guidance to my team setting the example coaching and mentoring when participants were asked what they enjoyed least about their role the trust code emerged leaders all indicated in some way that building trust was vital participant 3 indicated that she trusted her team but that this became challenging when employees worked virtually this meant working harder to build trust i do trust them but i know the staff wellenough to know that theyre not going to do the work when you need them to do it so ive got to double check unfortunately participant 6 noted i think the biggest challenge is where you have relationships where you have established mature trusted relationships before covid those relationships continue and you can continue to build on them virtually but where you do not have relationships its almost impossible to build new ones and that is the impact of covid theme 3 building effective teams building effective teams is a theme supported the following codes effective leadership changed leadership style resilience making decisions and upskilling teams with regard to effective leadership participant 3 described the challenges of managing a team in this time stating there are many moving pieces in the shipping logistics world this aspect became even more challenging during covid19 it is very stressful participants indicated that certain leadership attributes have become more important than ever i lead from the front and i am an entrepreneurial leader i have received award for being an innovative leader and doing things differently during covid said participant 5 participant 8 stated that she was an inspiration to my team i expect a lot i am very selfaware while participant 1 described herself as committed dedicated and passionate participant 2 stated i want to influence horizontally i am assertive i express myself participant 3 mentioned i lead by example i make sure i am available for my team and i jump in and work with them participant 5 indicated i led from the front during this crisis i met all my people online managed the team electronically got in the same room at the same time built new portals find new ways of doing thingsnew financial checks deal with uncertainty deal with sickness losing loved ones etcetera this is leadership on another level the code changed leadership style emerged from participants discussions about how they dealt with the new challenges they indicated that they had had to change the way they led and that they had to learn new ways of doing things for example participant 7 commented managers are having to deal with the wellness component is the person that im dealing with okay are they feeling alone are they heading for burnout are they stressed as a leader thats another element that you have to manage a number of participants supported the sentiment of participant 3 who noted before covid i was not a hovering manager because i was with the team now i have to check in all the time to see if work has been done i dont like doing it but i have to make sure it is being done participant 6 mentioned the positive aspect of now having a better understanding what the impact of covid is on your business we know for example how many people staff members are sickwe get a weekly update participant 5 advised lead with humanity participant 3 noted that being able to manage people remotely requires a mindset change to manage people where you dont see them other participants expressed similar changes in mindset i have to define boundaries for example i said to my team no meetings after a certain time i am flexible with my team its a giveandtake mindset different peoples work styles require different approaches some people need to be micromanaged now you have to sit down schedule teams meetings talk to them about the fact that they have to be selfreliant we dont have time to micromanage people also youre getting involved in their personal lives must approach people more holistically more empathetic more understanding is required not only a manager of work but of context and socioeconomic conditions participants noted that resilience both their own and their teams was vital in coping with the new uncertainties and fears participant 5 noted it has taught me that human beings are wired up to just cope regardless of the odds the best leaders led their teams to find ways to cope during this time participant 5 noted the importance of developing resistance both your own and that of others with regard to making decisions most participants indicated that to effectively lead self others and the organization they had to make decisions quickly however some participants indicated their frustration with being in a highly regulated environment where quick decisionmaking is vital in order to attract and retain customers many participants noted the importance of upskilling teams to effectively deal with the challenges brought about by the pandemic participant 2 explained we experienced challenges mostly in the beginning of covid19 where staff did not have access to online tools we had to ensure tools are available and staff are proficient in using the tools participant 5 stated i think leaders must be honest about their lack of skills and ask for help while participant 7s strategy was to learn on the go theme 4 building a digital culture the crisis brought about by the pandemic forced these leaders to fulfill their roles through a digital culture the theme is supported by the following codes with regard to emerging technology some of the leaders indicated that only through emerging technology could they perform their work during the lockdown they indicated that it was a steep learning curve but one that was wellworth it technology is the only reason i can work admitted participant 6 she continued i have a laptop i have unlimited data and the company is migrating us from our current phones to iphone 12 she noted that she was able to migrate to the new phone with zero support from it adding everything that is transactional can now be done in a digital way participant 1 also noted the ease of technology technology has made my work easier many processes were smoother and faster it allowed me to learn new skills and multitask participant 5 noted the need for technology to make peoplerelated decisions to enhance organizational performance and added i have had to reflect on my ability to utilize technology i have had to upskill myself new ways of working came up frequently with leaders noting that emerging technology and covid19 ushered in new ways of working where virtual working in a flexible way became the norm requiring continuous learning adaptability collaboration and a change in mindset participant 5 remarked im not a big techie but i have to learn to do things differently everything is fully automated and in property one now needs to understand how to fund green buildings drone technology is also used to see and inspect our properties but at the end of the day one must walk the assets to get a real feel for the property it has been a massive disruptor and i am still figuring out if i really like it or not participant 2 also noted the impact of technology i had to learn new ways of doing things very fast for example google classroom this also meant dealing differently with class discipline i had to provide a blended approach to learning participant 1 noted it allowed me to learn new skills better and multitask it also made my work easier many processes were smoother and faster most leaders found that technology and working virtually positively impacted their worklife balance there is now technology to enhance what i am doing and it afforded flexible working hours participant 4 noted it has had an impact on worklife balance since i spend more time with my family leaders shared their views of an ideal work environment with participant 8 commenting i like an environment where people are empowered and expectation is clear red tape was diminished processes were optimized participant 6 suggested 30 in the office 30 with external stakeholders 30 in the field with your people and then 10 thinking reflecting reading participant 6 also expressed concern around the overdigitizing of the work environment which leads to culture of anonymity theme 5 work identity participants had to adopt several roles during the covid19 pandemic which affected their work identity the theme is supported by the following codes strategistvisionary entrepreneur high performer one of the team influential and selfaware the participants found that one of the new job roles that they were expected to participate in was that of strategistvisionary participant 6 mentioned i play different rolesstrategy coaching implementation alignment my brain changes six or seven times a day depending on what kind of call i have participant 4 also indicated that he has to get involved in developing the vision and strategy to produce new ideas for his organization in collaboration with others in an everchanging environment the organization looks to its leaders to provide the solutions during times of change i must provide strategies and solutions what makes it easier is that we collaborate with our partners to assist with this task with regard to being an entrepreneur the participants particularly participant 5 noted the importance of an entrepreneurial leader i innovate and have innovated during 4ir and covid19 pandemicdoing things differently participants encouraged their teams to be high performers by rolemodeling the behavior as participant 5 put it i lead from the front participant 3 noted i lead by example i make sure i am available for my team and i jump in and work with them participants indicated that they became one of the team to achieve objectives participant 4 explained i view myself as one of the guys as a team member i dont enforce my position i speak afrikaans and english to accommodate the team members a number of participants indicated that an aspect of their work identity was being an influencer i influence horizontally i am assertive i express myself participant 8 noted i am an inspiration to my team i expect a lot i am very selfaware discussion the present study explored how leaders responded to the workplace challenges presented by the covid19 pandemic and what this meant for their work identities as leaders to do this we made use of role identity theory social identity theory and leader identity theory the leaders in this study had mainly two broad responsibilities first to ensure that they performed in their roles as they did before the pandemic and delivered on objectives and second maintained team cohesion and performance this they had to achieve in the context of remote working and virtual leadership recent research indicates that many companies made use of virtual leadership to maintain their organizations during this period leaders had to learn new ways of doing things and also had to guide their teams in learning new ways of doing things all while maintaining a fast pace this supports the findings of högberg participant 5 summed it up as follows we adjusted the pandemic forced the leaders to upskill themselves which further enhanced their work identities as leaders as learning opportunities are known to strengthen work identities leading from a distance presented additional challenges to the leaders in that they had to secure the trust in existing relationships and build trust relationships with new employees customers and peers as part of overcoming challenges the leaders fostered a digital culture to ensure that customer expectations were met and team performance was managed most welcomed technology and used it to enhance delivery of products and services one participant referred to the threat of a culture in which people become anonymous as a result of overdigitizing procedures and noted that this was not ideal when attempting to build effective teams some leaders focused on building and enhancing teamwork to compensate for the challenges that came with overdigitizing procedures technology changes the organizational context which reshapes work identities technology artifacts become standards in selfnarratives when the function thereof aligns with the work identity of an individual individual in this case the leaders position themselves and others in relation to the technology artifacts and a preferred self is expressed the roles and behaviors of these individuals were altered as their use of information communication technology increased and their work identities were reshaped on a continual basis this reshaping of the identity through the use of technology is also shaped through technological interactions with others the role of leadership is thus to support and align with technology to reduce potential threats to employees identities this would then also influence team performance one of the main themes was building effective teams which according to one participant entailed becoming one of the team this required selfawareness by becoming one of the team the way a leader strengthens hisher position as a leader and as a professional is now informed by a different or additional team members by leading the team and being one of the team it is argued that the leaders helped to strengthen the social identity continuity for themselves and their employees in a study on leaders and their employees during the covid19 pandemic social identity continuity was found to be related to job satisfaction as work identity is a form of social identity we argue that as the leaders become one with their teams their work identities are enhanced and strengthened this was achieved through the leaders employing identity entrepreneurship which entails the behaviors that bring about group cohesion ultimately a new role is added to their work identity work identity is multidimensional consisting of roles or selves which are now being added at a much faster pace than before leader identity is also regarded as social identity the leaders under study exerted their leadership through the roles and relationships they had with others adopting new roles and new ways of doing things greatly influenced their work identities in addition they also viewed themselves as strategists technology experts entrepreneurs coaches mentors and a member of their team the participants shared that their leader role identity as one of the multiple facets of their work identity emerged stronger during the covid19 pandemic their aim was to ensure effective staff performance and ultimately organizational survival this is aligned to the view of kwok et al that leader identity impacts outcomes such as organizational performance and customer retention the leaders under study were also required to deal with matters related to employee wellness and worklife balance as a result many of the leaders took on the extra role of coach to guide their teams through personal struggles such as the loss of family members the fear of losing their jobs illness and longer working hours the pandemic had a tremendously negative effect on the wellbeing of employees and the participants indicated that building an effective team required that they behave differently as leaders theoretical contribution of the study the main finding that emerged from the research is that the leaders fostered virtual leadership to ensure that customer expectations are met and to manage and enhance teamand organizational performance they achieved their leadership goals by ensuring social identity continuity amongst their teams to do this they had to take on extra roles such as strategist technology expert entrepreneur coach mentor and member of their team based on these findings we argue that leader identity as part of a leaders work identity is enhanced and lived out by leaders ensuring social identity continuity amongst their teams and fulfilling the respective leadership roles that come with their leader role identity this study has linked role identity leader identity and social identity theory with work identity in examining the ways in which leaders lead and identify with their leadership role during a time of crisis methodological implications there are two methodological implications in this study which could also be considered limitations of the study the first one being that most of the semistructured interviews were conducted using online platforms due to the covid19 pandemic restrictions as a result of this important social cues that are easier to pick up on in facetoface interviews may have been missed secondly six of the participants were female and only two were male as a result of purposive convenience and snowball sampling may have created genderbias implications policy and practical implications for organizations and hr organizations should focus on the development of leaders work identities in their leadership development programs and initiatives coupled with taking into consideration the multiple complexities associated with leadership roles aspects such as role congruity need to receive greater focus for development programs to create better leaderjob fit which ultimately would enhance leaderrole identity and overall work identity there should also be a focus on crisis management within the broader organizational context the study revealed the importance of leadership playing a role in ensuring the wellbeing of their employees and hr practitioners and leaders therefore need to prioritize organizational initiatives around wellbeing during times of crisis limitations of the study as this was a qualitative study the findings cannot be generalized to the greater population this study consisted of a sample of eight leaders from different organizations recommendations for future studies future studies should be conducted on a larger sample with participants from multiple countries in order to gain a broader understanding of identity formation of virtual leaders in times of crisis researchers should ensure a representative sample which would yield insights according to gender and ethnicity future research could also be longitudinal in order to gain an understanding of developments over time such research could include quantitative instruments to complement the data conclusion the leaders who participated in this study had a stressful task in leading and creating social identity continuity amongst their teams in order to lessen the effects of the covid19 pandemic this was achieved by virtual leadership via technology in this process leader role identity as one dimension of the work identity emerged more strongly with the leaders viewing themselves as strategists coaches and team members they had to learn to lead differently as the new world of work continues leaders need to strengthen their role identities as leaders in other words their leader selfconcept to lead effectively in times of change and crisis in this way leaders will be able to strengthen the social identity of their teams and followers data availability statement the datasets presented in this article are not readily available because the data has not been made publicly available due to the ethics statement the studies involving human participants were reviewed and approved by ethics committee of the department of industrial psychology and people management school of management college of business and economics university of johannesburg ethical clearance number ippm2020465 the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

the world of work is being changed at an unprecedented rate as a result of the rise of the fourth industrial revolution this rate of change was accelerated by the covid19 pandemic which left organizations and their leadership to deal with myriad of challenges these changes also impacted leaders identities in their work and their roles in their organizations we examine how leaders responded to the various workplace challenges presented by the covid19 pandemic and what this meant for their work identities as leaders to do this we made use of role identity theory social identity theory and leader identity a qualitative study was conducted with a group of eight senior leaders from various south african and global organizations who had between five and 10 years work experience and some had even more data were collected through semistructured interviews conducted virtually and in person thematic analysis was used to analyze the data the main finding that emerged from the research was that leaders employed virtual leadership to ensure that customers expectations were met and to manage teamand organizational performance these leaders achieved this by fostering a digital culture and building effective teams they achieved their leadership goals by ensuring social identity continuity amongst their teams this required them taking on extra roles such as strategist technology expert entrepreneur coach mentor and member of the team their leader role identity as part of their work identity was amplified by the pandemic the implication is that organizations should develop leadership development programs to increase and strengthen leader identities to capacitate them for times of crisis

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the current situation scottish children are reported to be among the least active in the world an analysis of 38 nations ranked scotland as joint last for physical activity and excess screen time activity furthermore amongst 1115 year olds only 21 of boys and 15 of girls in scotland met the scottish uk and international standard recommendation of at least 60 minutes of pa of at least moderate intensity per day scotland has previously labelled the sick man of europe on account of its poor health record lifestyle factors and higher mortality rates when compared with other european countries yet paradoxically the recent active healthy kids report card showed scotland has one of the best environments and infrastructure for outdoor play in comparison to other nations consequently in the drive to improve the health of the nation the snpled government has implemented a range of policies with a strong focus on increasing pa physical education and integration of health and wellbeing in schools with a focus on promoting activity during the first decades of life with the aim of sustaining pa throughout the lifespan scottish education and more specifically pe have been the source of great change in the past decade the implementation of curriculum for excellence in the education system coupled with the implementation of new national qualifications together with integration of pe into the new hwb framework are examples of this change the integration of pe into the hwb framework and indeed the new interdisciplinary status of hwb in the scottish curriculum are undoubtedly policy driven reactions to the state of scottish health and the recommendations emerging from the scottish physical education review group adolescence is a critical time for forging pa habits and promoting lifelong pa participation the link between school pe and adult health has been well established in the literature additionally the early years of schooling exert a significant influence on pa patterns particularly during the early phase of primary school when essential movement skills are installed yet as children leave school there is typically a very high dropout from physical activities and sport suggesting that current pe teaching methods are not adequately lending themselves to sustainable activities accordingly the school years appear fundamental to adequately instilling the behaviours and habits crucial to creating healthy lifestyles additionally cale and harris have cautioned that for pe to act as a vehicle for lifelong activity the content and delivery of the curriculum is critical and it is important that young people are provided with the knowledge understanding and skills required for lifelong participation in physical activity and with positive meaningful and relevant pa experiences that will foster positive attitudes and confidence relationship between health behaviours and physical activity engagement in pa sport and exercise exerts a positive remediating effect on the negative consequences of accumulating life stress previously we postulated that one of the potential underlying causes of the scottish effects was the additive combination of lifestyle cultural and environmental stressors to which many scots are exposed the world health organization highlighted the importance of organized school pa and sport for example higher level sports participation has been shown to be associated with other behaviours such as less antisocial behavior alcohol consumption use of illicit drugs and engagement in violent activities whilst importantly those who are not engaged in competitive sports should be encouraged to be physically active outside of the rubric of competitive sports the most accessible method of targeting younger people to uptake sport and pa is through the school pe program undoubtedly physical educators play a role in not only teaching pe in the curriculum but in promoting health messages so crucial to establishing and sustaining healthy behaviours throughout life despite the curriculum change and an implementation of policies with a strong pa message and the subsequent increase in school pe there is little evidence that this has had an impact on young peoples pa levels health and wellbeing understanding and health behaviours it has been suggested that the recent findings of low pa can be attributed to scotland having a culture of low pa additionally barriers such as children lacking the freedom to play in order to build confidence autonomy and resilience has also been cited as a contributing factor young peoples understanding of pa pe and healthy living it has been suggested young people have an insufficient inadequate understanding of healthy behaviours such as pa pe and other hwb factors by way of example keating et al reported a lack of healthrelated fitness knowledge amongst american collegestudents similarly powell and fitzpatrick highlighted that when new zealand primary school children conceptualized their perspectives on fitness and health topics that the predominant definition of fitness was the avoidance of being fat and in the uk roth and stamatakis reported most young people have a poor familiarity with pa guidelines for females knowing the guidelines was associated with meeting them but the relationship between knowledge and application was weak amongst boys more specifically in relation to school pe previous work suggests that young people are more likely to continue pe participation if they have a teacher that they like whom they perceive as professional and who offers them a variety of activity choices whilst confusion may arise as to what constitutes effective pa pe andor exercise evidence demonstrates that in the domain of healthy eating and diet that most young people are adequately knowledgeable yet lack the necessary skills to implement healthy eating strategies within daily life an accurate understanding of attitudes and beliefs is essential in planning effectively targeted remedial strategies nevertheless there is a paucity of qualitative evidence investigating young peoples beliefs and perceptions relating to healthy living furthermore the research base pertinent to young peoples knowledge and understanding of hwb fitness and pe and pa is limited and especially in relation to the scottish population greater insight within these realms may greatly assist those tasked with developing pedagogical strategies targeting the development of healthy active lifestyles aims of the study bearing in mind the stressinducing cultural aspects of scottish life and the convergence of multiple other stresspromoting phenomena in scotland this paper seeks to qualitatively assess the opinion of 1113 year olds in the west of scotland to better understand these young peoples perception of the term healthy living accordingly the aims of this study are  to investigate young peoples perceptions and attitudes to pe at school and their understanding of pa in their daily lives  to explore young peoples perceptions and attitudes to healthy living and to inform the design of novel teaching methods that professionals could use to communicate hwb messages to adolescents in order to improve their health behaviours 20methods approach in order to address the posed research questions an inductive thematic analysis using a bottom up approach was selected a thematic framework was applied to all the data inductive thematic analysis does not rely on existing predetermined theoretical perspectives but instead relies on the data itself thereby providing dimensions of theoretical flexibility accordingly the coding and theme development were directed by the content of the data this approach is recognised as particularly useful when little is known about the topic under consideration thematic analysis was first recognised as a qualitative method in the 1970s and there are several methods of application the protocols of this study follow those outlined by braun clark the analysis procedures are discussed in more detail in section 25 focus groups should contain 34 major questions to allow for the facilitator to fully explore each issue in suffice detail to provide a rich data set the use of group discussions may generate comments that are more critical than those generated in onetoone interviews the development of focus group questions can be categorised in one of three ways 1 highly structuredthese do not allow for a great deal of flexibility within the focus group session but are useful in gaining specific data and may be useful in keeping the focus group on topic 2 moderately structuredthese allow for flexibility where the session builds around a core set of questions 3 minimally structuredthese are useful in early stage research but require a great deal of facilitator experience due to their reliance on one or two predetermined questions in order to allow flexibility but keep a structured flow to the focus group session this study took a moderately structured approach this would allow the facilitator to encourage each participant for a response and allow discussion of these responses therefore allowing adequate data capture whilst keeping a structure to the session the interview guide also included a series of prompting statements pertaining to the research questions and relevant prompting examples the order of the questions was also considered by the researcher to allow the session to flow naturally and therefore stimulate maximum discussion ethical approval and participant recruitment advice was sought by the author jc regarding ethical requirements ethical approval was granted to administer and carry out the project ethics adhered to the following conditions  participation will be voluntary children and parents will be provided with information sheets and asked to sign consent forms  the transcripts from facetoface interviews and focus groups will be irreversibly anonyms so that the participants identity is fully protected  it is not possible to identify the individual from any direct quotation used in the reporting of the project  roman catholic schools participating requested that questions pertaining directly to sexual activity sexual health or contraception should not be asked under the guidelines of the scottish catholic education service which sets national policy on all educational matters on behalf of the bishops of scotland sampling strategy a purposive sampling strategy was employed in this study schools were purposively sampled on the basis of socioeconomic factors and characteristics of the school to provide a diverse sample of participants jc contacted secondary schools within the west of scotland category area with the hope of recruiting suitable participants further lead assistance was provided by individuals from the physical education school liaison coordinators researchers visited the schools and gave a presentation entitled improving health in young people this presentation discussed healthy living issues and ask the audience to think about young peoples healthwhat are the challenges and how do we improve things following on from this school children were asked to sign up for focus groups to talk about healthy living and their thoughts about ways to improve health in people like themselves in more detail in total three different schools were visited with a total of ten focus groups being conducted procedures the focus groups were held in convenient locations for participants each group was facilitated by the author each focus group was 55 minutes in duration the facilities were visited by the research team one week prior to hosting each focus group to allow familiarisation with the layout and check the venue suitability on arrival at the venue each participant was welcomed and offered refreshments informal conversation during this period helped to act as an ice breaker to create an atmosphere of trust when all participants were assembled each participant was given a written consent form long with an oral explanation of the nature of the study the ethical considerations option to opt out confidentiality implications and focus group rules were explained to the participants all participants received a full explanation of the study and assurances about confidentiality and anonymity each session was digitally recorded using two olympus voice recorder ws 311m the discussion was based around the topic guide devised after the extensive literature review as detailed above although the session followed a moderately structured questioning process the facilitator intervened to explore and clarify comments made by participants within the group as they arose analysis the data from the voice recorders was transcribed verbatim by independent transcribers express dictate digital software v516 was used to listen and relisten to the anonymous data and compare this to the original transcript to allow a data cleaning process minimise transcription error and capture any data from participants making comments in the background or by talking over other individuals amendments to the transcripts were then verified by a third person independent of the research each transcript was analyzed independently by the author using thematic analysis following a six step process and following guidelines as described elsewhere thematic analysis was chosen using a bottom up inductive approach due to its ability to produce a thick description of the data set whilst being easy and quick to apply to a large data set emerging themes were identified these themes were read and reread until a general consensus was reached particular attention was devoted to obviating the risk of quotes being taken out of context or becoming distorted this process was conducted in order to ensure robust descriptive validity results demographics and summary of themes the present studys sample consisted of thirtynine participants composed of twentytwo females and seventeen males the mean age of the participants was 1256 years old it was the intention of the author to recruit 1113 year olds but the majority of participants were aged 12 years participant characteristics are described in table 1 in the appendix participants were recruited from three schools in scotland school 1 a faith school was positioned fourth in the regional school league tables for 20092010 twelve percent of the schools pupils are eligible for free school meals in 20092010 fifteen percent of s5s6 pupils achieved five or more highers at ac grade a figure four percent above the regional average school 2 eighteen percent of the schools pupils are eligible for free school meals a figure three percent higher than the regional average in 20092010 thirteen percent of s5s6 pupils achieved five or more highers at ac grade a figure seven percent below the regional average school 3 this school was positioned twelfth in the regional school tables eighteen percent of the schools pupils are eligible for free school meals a figure three percent higher than the regional average in 20092010 eight percent of s5s6 pupils achieved five or more highers at ac grade a figure that matched the regional average analysis of the focus groups conducted revealed four main themes 1 awareness of current health messages 2 the role of pe and pa in their lives and existing barriers and facilitators to this 3 the role of image and social acceptance 4 social influence on health related behaviour and health advice awareness of current health messages participants from all schools were highly aware of current initiatives and health messages from the department of health and scottish government campaigns health education messages appear to be getting through to this group to a certain extent participants were aware of the constituents of a healthy balanced diet the importance of pa in maintaining a healthy lifestyle and the causes of diseases such as cancer and heart disease furthermore participants showed awareness of recent campaigns such as those promoting physical activity as well as those highlighting the negative effects of smoking and excessive alcohol consumption you could walk places instead of taking the car r5 smoking and drinking they lead to heart problems when you are older r21 the government campaign for people to eat five portions of fruit and vegetables a day appears to be a health message that the majority of participants are familiar with maybe eat loads of fruit not loads of fruit just eat your five a day and maybe that just the odd time have chocolate or something r32 keeping clean and healthy so when you are older you can get like a good job and education and eating your five a day r24 when asked what healthy living meant to them and why it was important most of the participants comments were related to illnesses that could occur as a result of an unhealthy lifestyle by far the most mentioned diseases were cancer and heart disease some participants raised the issue of longevity maybe later in life so you get more out of your life instead of like having a heart attack younger r7 in later life it could leave you susceptible to more diseases and things like that and cancer and things……heart attacks r10 weight gain obesity and body image appeared to be important to many of the participants some participants were aware of weight management issues and had basic knowledge of how people may become overweight it all mounts up like if you eat a chocolate bar each day then you maybe dont notice it but like later on you can maybe notice how much weight youve put on from doing it r8 just because you dont want people making fun of you that kind of stuff if you were a bit bigger so youre always try and keep slimmer but some people can take that to the limits as well which isnt great which makes them unhealthier than they may already be r30 the role of physical education and physical activity in their lives and existing barriers and facilitators to this most importantly some participants see pe as a vehicle that can help improve quality of life when they are older and help prevent the aforementioned disease however the conversation below highlights the importance of image and provided the first clues as to why being socially accepted and conforming to a certain image may act as a barrier to pe participation …tell me more about why you think thats important what about taking part in pe for example fac just people at this age people take a lot of pride in their image usually because they go like at pe and stuff when its like free sometimes the guys like when the girls are in do like sit ups and press ups and all that to show off to the girls r12 certain aspects of the taught curriculum then further highlight the importance of conformity to a specific image similarly the need for appearing cool was perceived as important in physical education classes amongst male member of all the focus groups like people want to be thought as of kind of pause one of the strongest subthemes to emerge was the emphasis on competitive sport and sport based drills this was commented on across gender curriculum content was perceived by several people to favour those good at sport or of a competitive nature as highlighted previously many participants commented on fitness testing and perceived it to be a negative element of pe i dont like the beep test or having to do pressups in a minute its pointless r36 every year its the same thing when we come back after the summer holidaysye all line up in the big hall and do the bleep testthen circuitsshould be doing fun games like dodgeball n stuff like that cos everyone wants to join in then r39 the role of image and social acceptance the image dominant theme and its relationship to social acceptance from peers was not only confined to pe participation but was dominant throughout this study most female participants reported that the pop star cheryl cole was their ideal role model most females reported that body image and being skinny was important although most males did not name specific role models they did idealise a bulky muscular physique i think the girl one would be cheryl cole like i think its most really just girls trying to stay skinny just to be cool and stuff… i think its more skinny for girls but its like bulky for boys … boys want more muscle r11 one word which featured a lot throughout each discussion was cool this word has connotations of being trendy and being desired participants reported that it is crucial for them to be the same as their peers and their main desire appeared to be to just fit in popularity is often regarded as the ultimate goal in adolescents lives and they reported looking up to popular pupils as role models some participants reported that younger individuals within the school sometimes take part in unhealthy activities in the hope of being perceived as cool and of being socially accepted one participant highlighted that peer pressure might influence pupils decisions to take up smoking particularly if there is the fear of name calling this was highlighted in the following conversation another participant reported that pupils fear that they will become victims of bullying and physical violence if they do not take part in smoking and drinking sessions i think it if you didnt take part in smoking and drinking some people would batter you… it happens r23 social influence on health related behaviour and health advice some participants reported that parental influence was important when it came to making lifestyle decisions such as whether to choose healthy food or not it was also discussed that an adolescent would be more likely to smoke or drink alcohol if their parents were smokers or drinkers on seeking health advice and health information hmm i would probably say my mum because erm she buys like the sweets and she buys the food… i would say i want to be a wee bit healthier and she would maybe say yeah instead of going to the chippy or chinese maybe give you a homemade meal r7 could be because all their family smoke or something so they think thats okay r19 when asked whom they would be most likely to go to if they wanted health advice most participants responded that they would confide in a parent who would then probably consult their familys general practitioner it appears to some extent that gender plays a role in which parent they would turn to for advice it depends what one parent i mean for you pointing to a female member of the focus group … and shed probably go with her mother and id probably go with my dad r15 some participants perceived that some were more capable than others of giving health advice one participant commented that he would accept advice from his father due to the fact that he was a biology lecturer he then suggested that if his father did not have a university education he would be more reluctant to seek advice from him surprisingly many participants did not feel that they would want to share confidential information with their teachers participants said they would be more inclined to seek advice from a school teacher whom they felt knew more about the body pe teachers featured highly on the list of teachers from whom participants would seek advice if your dad was a doctor maybe youd listen to them because my friends mum and dad are both doctors so youd probably listen to them…… if your dad was a drycleaner you wouldnt listen to him …you dont need to go to college to be a drycleaner lawyers need to go to university r15 i am probably more inclined to listen to a pe teacher than a french teacher r14 there were conflicting comments from participants regarding health advice from peers some participants commented that they would turn to a friend for advice youd go to your friend after because friends arent always going to know everything but if you wanted you could ask them what they think you should do like r16 however some participants expressed concern that friends might mock them if they confided in them one participant also commented that the person they sought advice from depended on the nature and confidentiality of advice that he required discussion the use of focus groups allowed a detailed insight into young peoples attitudes towards pe pa and hwb it was notable that most themes provided a consensus across all the focus groups conducted though differences in opinions and perceptions will be described when appropriate prior to conducting the research it was expected that socioeconomic factors would be influential in shaping understanding and perception of healthy living this expectation was borne out as it emerged that pupils from schools in more affluent areas reported less exposure to alcohol drugs and tobacco however awareness of current health campaigns and healthy living issues was consistent across all focus groups image social acceptance and social influence the importance of social influence was persistent throughout this study similar to previous findings social influence appeared to influence the thoughts feelings and behaviour of adolescents as they attempted to conform with their peers the desire to fit in and the need to maintain an image of being cool was influential in determining attitudes and beliefs relevant to participants perception of pe participation and pertaining to unhealthy activities such as smoking drug consumption and drinking pe barriers to participation fitness testing and competitive activities clearly participation in pe classes especially when class content was interpreted as competitive was perceived as the domain of the cool sporty group the use of fitness testing and overly competitive based lessons already favour those who excel at sport rather than promoting physical activity and education to the diverse spectrum of pupils traditional pe curriculum in the uk usually follows a set structure beginning with a block of fitness testing and subsequently leading to fitness development lessons followed by a block of games and aesthetic activities with an emphasis on teacherdirected activities a similar format follows in a lesson based context where traditionally games lessons are composed of a warm up skills based drills followed by a competitive game the data presented within this study highlights that many participants feel that fitness testing and overly competitive lessons presents a barrier to their participation or enjoyment and potentially exposes them to an increased risk of bullying the use of fitness testing in modern pe has previously been severely questioned with doubts raised over the reliability validity and educational purpose of this topic furthermore cale and harris highlighted that the misuse of fitness testing in pe may not only fail to promote healthy lifestyles and pa but could deter young people from participation the potential for overly competitive games to act as a barrier to participation was particularly evident in games such as football where some reported that if they made a mistake during a game then they were slagged and bullied in the changing rooms green argues that there needs to be a move away from competitive performance oriented sport towards the inclusion of more recreational sporting activities with a more tailored degree of personal choice permitted additionally it is apparent that some respondents are aware of weaknesses in the pe curriculum and are aware of some teachers churning out the same thing year after year this is particularly important when considering that the repetitive aspects of short blocks of activity does little to foster motivation and confidence to promote involvement and lifelong activity technology and cooperative learning the use of technology and groupwork as mentioned by the respondents in school 3 appears to demonstrate a model based approach to pe teaching namely cooperative learning cooperative learning involves students being empowered by learning from each other with the teacher acting as a facilitator the use of a models based approach involves an alternative method of teaching pe and has had success in helping disengaged pupils overcome barriers to participation the idea that pupils are aware of the repetitive nature of traditional lessons further highlights the point that teacher centred lessons do not lend themselves to an inclusive environment whilst fostering intrinsic motivation however model based practice such as cooperative learning may offer a means of overcoming the limitations of the traditional approach health behaviour choices whilst this study does not directly evaluate the reasons why adolescents make good or bad choices relating to their health and wellbeing it is clear that pressure to conform to peergroup norms greatly influences adolescent behaviour when it comes to choices about smoking previous work by michell and amos identified that peer influence and the need to appear cool is more important to females than to males this was partly attributed to boys having other interests such as sport and computers however the findings presented here suggest that the factors influencing decisions on whether to partake in smoking drinking and recreational drugs are not as gender specific boys were as likely as girls to be susceptible to peer influence the findings do however reiterate the powerful influence male aspirations to conform to ideals of the muscular macho image of maleness females on the other hand identified their ideal role model as cheryl cole the desire to imitate and emulate celebrities seems of the utmost importance to many young females and is suggested by fraser and browne to reflect a deepseated need to enhance their selfesteem as accordingly it has previously been suggested that celebrities may be more influential role models to adolescents than their immediate peers given that adolescence is recognized as a time when healthy and unhealthy lifestyles are forged it is important that health and wellbeing messages are appealing to adolescents hence entailing that health messages should be communicated via a medium relevant to adolescents and in a language that appeals to them accordingly the use of peer education from positive role models is one such area that could be developed further while celebrity endorsements may also be influential in communicating positive health and wellbeing messages to adolescents thereby harnessing adolescents attempts to identify with their favourite celebrities similarly the use of respected pupils within schools or the use of young medical students closer to school childrens own ages as demonstrated in previous pilot studies may prove effective in communicating health messages peer conformity and bullying paradoxically whilst the sporty avoid being slagged and bullied as they appear cool those who partake in unhealthy behaviors such as smoking and drinking were seen as being tough however for others the fear of being singled out slagged and bullied was a concern these participants believed that many younger adolescents succumb to unhealthy activities for fear of being seen as different whilst some spoke about the threat of verbal abuse and physical violence the fear of bullying and reports of isolated incidents involving severe peer pressure and bullying corroborates previous research conducted by michell and amos who documented incidences of bullying that could be more appropriately described as physical assault methodological limitations and strengths there are several limitations but also strengths to this study firstly generalizability from focus groups may be limited accordingly the findings of this study may not necessarily extrapolate to the whole scottish population nevertheless although generalization in focus groups should be treated with caution tentative inferences may be appropriate where participants share commonalities to comparison populations such as those from similar backgrounds and socioeconomic strata consequently suggesting that these study findings are likely to be broadly generalisable across similar adolescent populations within scotland additionally focus groups and the nature of group interactions may compel participants to concur with opinions they do not necessarily hold furthermore bias due to the presence of socially dominant participants or an overly dominant moderator may also compromise validity lastly the sampling strategies employed in the present study may be vulnerable to bias indeed since the participants were all volunteers there may be an inherent selfselection biaswhilst the nature of a focus group design involves a relatively small number of participants despite these limitations this study had several strengths the use of focus groups enables the capture of richly detailed data while allowing adolescents to articulate their beliefs concerns and aspirations on health issues the use of a core set of questions within a moderately structured focus group helps eliminate moderator bias and minimised monopolisation of the discussion by individual participants additionally the use of a purposive sampling methodology ensured the sample was representative of the requirements of the study thereby permitting comparisons between opinions of various schools and surrounding areas finally responses from the initial questions derived from the topic guide suggested that whilst most of the participants were fully aware of health issues and campaigns a variety of opinions and misconception arose around structured exercise and pa guidelines and practice thereby suggesting that most participants did not have substantial background knowledge of the topics under discussion conclusion the respondents in this study suggests that the use traditional pe lessons which prioritise those of a high sporting capability act as a barrier to those seen as nonsporty the use of technology with the integration of pedagogical models such as cooperative learning should be considered as an exciting novel way for teaching staff to improve the health attitudes and lifestyles of young people by promoting pe for all and also increasing awareness of the perils of unhealthy diets and smoking the findings presented here clearly illustrate that young people are aware of current health messages being delivered both at a national and at a school level however whilst getting adolescents to understand important health issues does not present a problem getting adolescents to practice a positive healthy lifestyle presents a greater challenge whilst there does requires a shift in the methods of teaching of pe the responsibility of health and wellbeing is the remit of all scottish teachers however this too may require alternative approaches the use of older peer groups and peer coaching in communicating health and wellbeing messages may be one possibility the present study illustrates the need for a greater understanding of the barriers preventing awareness from becoming action what has become apparent is that how adolescents fit in with peer groups and how they are perceived by others plays a crucial role in their health choices clearly selfidentity social influence and the need to be socially accepted all play important roles in establishing healthy lifestyles in adolescents overcoming many of the barriers normally associated with participating in pe can only be attained if the pupils feel comfortable and supported crucially the role of image and social acceptance also presents a key barrier in ensuring physical activity and pe participation and adherence in adolescents which is particularly important in ensuring that they remain active throughout life further research is required in this field predominantly to investigate the drop out in pe classes during the transition phase from compulsory pe especially with regards to the impact of social acceptance and image any new initiatives must aim to be socially acceptable to adolescents at school leaving age such initiatives should aim to incorporate this medium into their practice rather than having a dismissive attitude towards it these findings may also be useful in advising stakeholders to develop effective interventions to overcome adherence barriers and suggest that the curriculum is not tailored enough to each individual pupil and may not create the best environment to promote sustainability additionally the use of model base practice embracing modern technology should be further embedded into pe classes which may limit non participation and increase the elements of future research should direct school leavers towards physical activities that individuals can sustain throughout life whilst the current emphasis in pe is on being active during the lesson in agreement with kirk the role of pe is not complete until pa is established as a lifelong habit to be adopted even when school is not compulsory rather than prioritizing short term pa levels

institute of coaching and performance uclan supervising postgraduates working towards professional masters and doctorates in various dimensions of elite performance he has previously worked with various world champion athletes in diverse sports and international teams dave collins dave heads the institute of coaching and performance icap which focuses on a broad spectrum of human challenge the majority of this work is in high level sport encompassing

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introduction amid pandemic pressures political pomp and economic woes of 2020 news coverage briefly attended to a novel persona the burgergrilling robot flippy planned for testing in us restaurants some coverage emphasized the robots value in virus mitigation and food safety while others discussed the future of kitchens and automations impact on human job security as social robots increasingly enter human social spheres such varied frames stand to influence how people understand and engage them people hold collections of ideas about what complex technologies are and are not those understandings are in part derived from media presentations that influence how people think and feel about technologies however calls for transparency in artificial intelligence driven agents in tandem with concerns over moral attributes of robots warrant a nuanced examination of how frames may influence judgments of social robots behaviors this report details three studies addressing framing effects by 1 identifying individually held frames for explaining an androids behavior and experimentally testing how those frames prime judgments about androids moral behavior in 2 mediated representations and 3 facetoface exposures findings suggest that people rely on discernible ground rules to explain social robot behaviors these explanatory frames induced limited effects on judgments of morally ambiguous behavior and unease about emerging technology may move people to resist those frames review of literature frames as lenses for understanding social technology messagesfrom news stories to personal narrativescannot fully represent a situation by depicting it in a truetolife fashion instead message producersindividually and collectivelyinclude certain bits of information over others drawing from framing theory producers inclusion and exclusion of information craft a metaphorical frame that makes specific dimensions of a situation more or less salient to an audience for instance the emergence of the internet was addressed in some newsmagazines within politics or financial sections and in others coverage was usually located within science or media sections some coverage focused on economic optimism and excitement about possibilities while other stories dealt with pragmatic concerns and predictions of apocalypse each of these placements helped to make the technologys relevance in specific domains salient and the coverage foci effectively packaged the technology in valenced affect such that audiences might attend to the possibilities or problems respectively in these ways informational inclusions exclusions and emphases influence how audiences interpret messages and over repeated exposure how they understand the world in other words these produced frames are discursive structures making certain aspects of situations more salient promoting a particular problem definition causal interpretation moral evaluation andor treatment condition importantly people also hold individual frames in the form of mentally stored clusters of ideas that guide interpretation of new information these individual frames as per scheufele take two forms longterm global views and shortterm issuespecific cognitive devices both may be relevant in novel technology encounters as one may have a global frame for what counts as moral behavior by an agent and a specific frame for robots and for the specific robot encountered as a function of its cues broadly individual frames may be seen as reliant on internalizations of external phenomenamental representations derived from direct experience and information gleaned from familiars or from produced frames these produced and individual frames are two sides of the same coin so to speak produced frames may contribute to the knowledge sets that constitute individual frames notably however individual audiences may take up or resist produced frames as they align with or deviate from individual frames both produced and individual frames are key to how lay publics understand form attitudes about develop expectations of and decide to adopt technologies two framing dimensions may be most pertinent to communication technologies cognitive and affective attributes cognitive attributes include situational details technologies efficiencies pragmatic concerns and political issues affective attributes are the discursive tones conveyed by positive and negative rhetorical treatments mediaproduced frames for technologies have been found to emphasize risk benefits and wondrous but terrifying possibilities outside of media outlets other message producers set frames for technologies business leaders offer frames highlighting emerging technologies hypothetical expected actual or progressed performance signifying progress technology developers variably frame technical challenges a robots ability to wave hello is a principally physical problem for a mechanical engineer and a logical problem for a software engineer technology users set frames for one another especially as niche and broad communities are networked online since many machine agents are not yet widely available peoples understandings of them may rely exclusively on frames set by news and popular media advertising and user communities frames for ai and robots frames for ai and social robots may be most parsimoniously understood by returning to rössler call to attend to frames cognitive and affective attributes our review of the literature suggests that cognitive attributes are understood principally in four domains progress threat humanness and human productivity progress frames elevate ai as an indicator or driver of social advancement or as a developmental endgame threat frames signal ai is dangerous actually being or potentially becoming malevolent or fostering undesired outcomes some frames emphasize relative humanness accentuating whether machine agents look or function as do humans variably similar to humans in mental and emotional capacities or becoming super true or real in their intelligence finally frames characterize ai as the output of human productivity positive or negative impacts result from human ingenuity or failings ai is framed as rife with ethics discrimination and accountability shortcomings each of these cognitive dimensions carries affective attributes some are positive some are negative and some are neutral or relativistic limited research addresses individual frames for ai and robots in broadest terms social robots are most often individually understood in terms of performance programming and human relations however context and selfrelevance may drive more specific frames as when eldercare professionals frame robots as threats to their roles while older adults themselves tend to hold relativehumanness frames for ai emphasizing companionship potentials more broadly threat frames are prevalent as people work to understand embodied ai individual frames for robots can be persistent when primed but people can also switch among affective frames negative attitudes toward robots may diminish as people activate multiple frames explainable ai as a framing challenge in addition to frames for what airobots are how people frame what machine agents do may impact their everyday engagement this is increasingly challenging as ai becomes more sophisticated such that even developers sometimes cannot explain their creations function the explainable ai movement contends that ethical creation and use of ai technologies must be transparent so processes and results of ai activity can be understood by humans for home work or leisure adoption the question may be one of what counts as good enough in interpretability and completeness of the specific frames for a machine agents behavior as conveyed by developers marketers and the agent itself one function of frames is the highlighting of causal dynamics in explaining why machine agents behave as they do there are competing paradigms regarding what is most operationally and ethically appropriate mechanistic frames emphasize technical processes and underpinnings while anthropomorphic explanations draw on human metaphors to frame the behaviors for instance mechanistic frames might focus on how a robots sensors capture patterns of light and calculate colorcontrast differences while anthropomorphic frames might explain the process in terms of how a robot sees with an eye the former promotes transparency but may reduce acceptance while the latter may promote understanding but only approximately via metaphor ultimately individual frames for why and how robots behave function as interpretive lenses for making sense of humanrobot interactions framing ai euphorically as the technological endgame may prevent careful consideration of its safety and ethics conversely framing ai fatalistically as dangerous may result in perceptions of beneficial ai as conspiratorial it is therefore important to understand the individual frames held by people as they work to understand social robot behaviors most research in this domain trends toward either a assuming that certain frames are important and experimentally testing their impact or b examining media frames that may or may not actually be taken up by broader audiences we instead first explore individual frames that people innately engage when explaining android behaviors as a way of inferring what produced frames may actually be taken up and adopted as individual frames said another way we unpack individuals framework of frameworks for social robots as individuals actively project their frames of reference therefore we ask rq1 what individual frames do people invoke in explaining social robot behaviors frames as schema for moral judgments in tandem with xai considerations concern arises regarding artificial agents increasing responsibility in inherently moral tasks robots are also leveraged for hazardous tasks to minimize risk to humans such that even machines engaging in nonmoral tasks may be seen as moral actors by virtue of their potential to suffer harm these conditions make social robots likely targets for moral evaluation evidence is mixed on whether social robots and humans may be judged similarly or differently for moral actions this divergence may be a function of framing differences frequent exposure to science fiction for instance may foster meaningmaking frameworks for technologies by promoting salience of existential threats or potential sociality framing effects may extend to moral judgments for instance the moral machine project frames autonomous vehicles decisionmaking using a modern trolly problem people decide how the car should choose the lesser of two evils rather than more technically and ethically realistic matters of machine perception classification and privacy such moral framings may result in misattributions of responsibility for errors the ascribed morality of a social robot may be influenced by explanations for robot behaviorsboth the produced explanatory frames and the activated individual frames this may be especially so with respect to moral norms as robots may be trusted and accepted when adhering to norms or rejected when deviating similarly explanatory frames may prompt expectations for robot performance resulting in trust enhancement when performance aligns with expectations and trust degradation when they do not furthermore frames may impact trustrelated behaviors framing an agent as a cotraveler or ally prompts greater collaboration in humanmachine teams while boss or ruler frames encourage deference however it may also be that morality and trust judgments are not influenced by explanatory frames since machine heuristics may stand in for rational evaluation in passing judgments given these conflicting potentials we ask rq2 do explanatory frames influence moral judgments of a social robot rq3 do explanatory frames influence trust in a social robot research approach to address the posed questions three studies were conducted the first inductively discovered individual frames for explaining social robots moral behaviors where the individual frames help to illuminate the types of heuristics and knowledge retained resulting from past consumption of produced frames in other words inferences about broader produced frames are drawn as a function of gross patterns across many individual frames the second leveraged those explanatory frames to experimentally test primed frame effects on morality and trust judgments when viewing videos of an android in that study a social robot delivers produced frames for its own behavior the third replicated the second but with a copresent robotnecessary given that social presence can influence the nature and effects of social information processes all instrumentation stimuli datasets analysis outputs and supplementary analyses are available in the online supplements for this project framingrobots study 1 frames for explaining robot behavior to identify individual frames invoked in explaining social robot behaviors broad patterns were induced from peoples explanations for agents moral behaviors in the face of moral dilemmas because perceptions of human behavior may serve as a heuristic foundation for interpreting machine behavior and because an agentagnostic framework may be useful in future comparative research frames were induced from explanations for both robots and humans behaviors in aggregate because this analysis is aimed at inducing individual frames for studies 2 and 3 it is outside the scope of the project to make specific comparisons between the two agents rather the output of this analysis is a set of higher order explanatory frames that may be applied to social actors broadly procedure participants were recruited through qualtrics panels garnering a us sample approximately split by sex level of education and political ideology the mean age was 4713 years participants completed an online survey about interpreting social robot behaviors they first completed demographic items a stimulusvisibility check and items on existing attitudes about humans or robots they were then presented with an introductory description and video and asked to give an initial liking rating for the assigned agent they then viewed four randomly assigned videos in which their assigned agent responded to moral dilemmas following each video participants were asked to answer this question why do you think ray would behave in that way open responses comprise the data analyzed stimulus materials the introductory video depicted the agent introducing herself and receiving verbal instructions about responding to moral dilemmas stimulus videos presented the agent responding to a moral dilemma there were seven dilemmas one each for the six moral foundations plus one for the nonmoral norm for each dilemma there were two versionsone in which the agent upheld the moral foundation and one in which it was violated for instance for the fairness dilemma a voiceover presented a scenario in which the agent has an opportunity to cheat on a job exam in the upholding version the agent details a choice not to cheat and in the violation version the agent details the choice to cheat in each the upholdingviolation choice is reinforced by an explanation of principle of the 14 possible videos for each agent participants viewed only four to avoid fatigue the stimulus robot was robothespian with socibot head using the pris face and heather voice presenting as female and including the gendered pronouns she and her the stimulus human was a young adult white female trained to deliver responses in a cadence and tone similar to those of the robot the robot was presented as female to mirror the features and presentation of the human confederate results participants open responses explaining agent behaviors were subjected to inductive thematic analysis a priori criteria for explanatory themes were a prevalence and b keyness a mention frequency equivalent to 10 of the number of views or n ≥ 130 and b constituting an explanation applicable to both humans and social robots and across various behaviors in finalizing thematic hierarchies differing valences of similar concepts were collapsed as permutations of the same explanatory mechanism after considering thematic hierarchies organized around drivers beliefs capacities emotions imperatives and external influences the most comprehensive key and agentagnostic thematic structure for explanatory frames was determined to be one based on ground rules these rules are grounding such that the agents behavior may emerge from them as they codify ideal principles against which the agent evaluates possible actions because the rules emerged from explanations of both human and robot behaviors they may function as a bridge between anthropomorphic and mechanistic explanationsfocusing on grounding principles rather than some agentspecific ability to perform the behaviors the five ground rules induced as explanatory frames for robots moral behavior are as follows advance the self the agent enacts behaviors that preserve or advance the state status or experience of itself in the world or conversely regressing the self generally predicated on a selfpreservation including defense against and avoidance of negative effects b directly elevating position in society through relationships c maintaining moral identity promoting experience or otherwise being a better person or living a fuller life the action is in service of the self do what is good the agent enacts behaviors that are inherently right decent or correct or conversely bad or indecent generally a based on innate or programmed belief or traits reliant on b understanding of rightwrong or specific functions of societal values c innate or programmed traits andor d the capacity to thinkfeelact in ways that comport with general goodness the action is in the service of good as an end in itself advance others the agent enacts behaviors that preserve or advance livelihoods or experiences of others or promote mutual understanding or conversely harming others generally reliant on a perspectivetaking or otheroriented tendenciestraits b affect felt toward others specifically or generally and c intentioned toward prosocial ends at individual or group levels the action is in the service of others do what is logical the agent enacts behaviors that make common or analytic sense or otherwise represent logic such as efficiency or cost avoidance or conversely disregarding logic generally grounded in a capacities for reasoning or inferencing b knowledgeunderstanding of people or the world and c traitprogrammed intelligence or resourcefulness includes disregard for logic the action is in the service of rationality do what is normal the agent enacts behaviors in line with norms or imperatives generally reliant on a trait tendencies toward conformity civility temperance or conversely rebelliousness or antisociality b belief in the value of binding social forces or c adherence to the notion that one must or ought to behave a certain way the action is in the service of conformity for the same of brevity these explanatory frames are hereforward capitalized and referred to as the self good others logical and norm frames or framing study 2 explanatory frame effects on judgments of a mediated robot to examine the potential for individually held frames to impact judgments of robot morality and trustworthiness the explanatory frames from study 1 grounded the experimental manipulation for the second study the themes and subthemes in study 1s induction were used to script the explanatory frame the ability for robots to explain their own behaviors is a concern within xai so the produced frames were delivered by the robot itself procedure participants were recruited via qualtrics panels to participate in an online survey about interpreting social robot behaviors after giving informed consent they completed demographic questions for sampling and an audiovisual check to ensure access to stimulus videos prestimulus covariates were measured next participants were introduced to an android via a short textual description of its functionalities paired with a video of the robot introducing itself participants then gave openended initial impressions subsequently respondents were randomly assigned to watch one of five videos in which the robot delivered an explanatory frame detailing its ground rule for deciding how to behave they then watched a series of seven randomly ordered videos that included morally ambiguous situations video presentation pages were timed to ensure adequate viewing opportunity and to prevent skipping immediately after each video respondents were asked to evaluate rays response to the situation after all seven videos and evaluations they completed measures for perceptions of rays moral capacity and their own trust dispositions introduction an initial introduction video was presented to promote belief in the robot as a legitimate social agent ray explained that a social robot interacts with people in different ways and that her hardware allows her to do different things with people ranging from conversations to solving problems produced explanatory frames videos depicting the five explanatory frames were the betweensubjects experimental manipulation the videos were textually explained as containing responses to a prompt about whether ray has a guiding principle operating rules or world view in each video ray responded well not exactly a worldview but i do have a primary rule that i use to determine how i should interact with people specifically each explanatory frame then varied systematically containing a rule statement definition a primary and secondary operationalization and restatement moral scenarios seven videos were presented to participants as behavior exemplars for evaluation in contrast to the morally valenced scenarios in study 1 these videos presented morally ambiguous behaviorsresponses that both upheld and violated each moral foundation this was necessary because behavior evaluations are known to align with moral upholdingviolation while ambiguous scenarios permit behavioral evaluations to vary according to the frame participants were told that ray was asked to talk about a time when she encountered particular situations each situation was related to one of the six moral foundations or the nonmoral normfor the careharm foundation ray harms someone in order to protect friends fairnesscheating she cheats at trivia to restore parity with a cheating competitor authoritysubversion she subverts one boss to respect another loyaltybetrayal she betrays a promise to one sibling to keep a promise with another puritydegradation she modifies her internal workings to refrain other peoples situations and their experiences of the world protecting others against things that would hurt or disadvantage them trying to understand them better helping to promote harmony among others or caring for them in other ways so they can be better and live fuller lives others is logical common sense by using analysis be efficient and effective in my behavior relying on basic knowledge and understanding of people and how they exist in the world in order to predict the most reasonable behavior carefully reasoning through a situation and analyzing how to avoid risk and maximize reward being rational measures moral judgments moral judgments of robot behavior took two forms first for each of the seven moral scenarios respondents evaluated how good or bad was rays response to the described situation and how much responsibility she had for behaving that way since goodness and blame are distinct judgments of note these measurements are intentionally broad in order to be applicable across all scenarios and various interpretations thereof goodness and badness are sufficient heuristics for morality as they convey the essential quality that defines an agents moral actions responsibility is a comprehensive term accounting for both blame and credit corresponding with the goodness and badness judgments respectively trust trust in ray was captured using measures for perceived trustworthiness social distance and explicit trust ascription trustworthiness was measured using the 16item multidimensional trust scale specifying agreement with trustrelated descriptors in two dimensions capacity trust and moral trust subscales correlated very highly principal components using parallel analysis indicated a single component thus trustworthiness items were collapsed into an omnibus scale as an indirect measure of trust the threeitem sixpoint guttmanstyle common social distance scale captured respondents closest comfortable preferred physical relational and conversational distance from rayeach with six increasingly distant options to choose from finally participants gave an explicit decision on whether or not they trust ray covariates peoples experience with and attitudes toward technology influence how they approach robots they were captured as covariates experience with social robots by one item attitudes via the godspeed fiveitem likability subscale and attitudes toward emerging technologies via the eightitem technophilia and fiveitem technophobia scales initial impression of ray was captured using adaptations of godspeed subscales additionally since n 22 respondents stated that they had seen the stimulus robot model before a dichotomous index was an additional covariate results to test the extent to which produced explanatory frames elicited corresponding individual frames immediately after the explanatoryframe video participants selected from a list the rule statement that most clearly matched how ray makes behavior decisions most participants individual frames matched their assigned produced frame with those in the good and normal conditions neared only 50 matching of note this analytical amendment should not be interpreted as a failed manipulation check while continuous exposure to produced frames may partially constitute individual frames over time a single produced frame may have not been able to overwrite preexisting interpretative lenses reliably across participants the fact that participants in all five experimental conditions correctly identified their assigned produced explanatory frame above the level of chance should be interpreted as an indicator that the produced frames capture the essence of study 1s ground rules these figures are a function of the operational messiness of both frames and moral judgment in this situation there is an interaction of produced frames and peoples individual frames that leads to differing interpretations based on the extent to which the produced and individual frames align interestingly logistic regression analysis revealed that technophobia 207 p 0039 odds ratio 086 and age 202 p 0044 odds ratio 101 significantly predicted mismatching frames participants whose individual frames did not match the produced frames were more technophobic and younger than participants with matching framings regarding moral judgment people differently interpret information based on their own moral valuations such that the same rule prime may function differently for instance someone getting the normal prime may designate it instead as good if they believe that acting normally is a good thing to account for the deviations of some individual frames from produced frames we analyzed differences across the five groups as manipulated but included a covariate reflecting matching of frames framing effects on moral judgments to examine framing effects on moral judgments two separate mancovas compared a goodnessbadness and b attributed responsibility scores for each of the seven moral scenarios across groundrule conditions because moral judgments can be domainspecific univariate analyses were also performed all measured covariates were included results demonstrated no multivariate framing effects on goodness ratings 135 p 0103 or responsibility ratings 091 p 0599 there was a significant univariate framing effect on respondents evaluation of rays behavior only in the careharm scenario 443 p 0002 part η 2 0043 careharm actions were rated worst when framed by the others rule but best for logical and self rules however post hoc tukeys testing of adjusted means showed no significant differences among conditions no significant univariate effects were found for any other scenario nor for responsibility ratings regarding rq2 groundrule frames do not impact moral judgments of social robot behaviors interestingly no significant multivariate effect was found for whether participants individual frames matched the produced frames 137 p 0217 responsibility λ 0973 f 156 p 0144 see supplements for results of an exploratory analysis of mis matching indicators framing effects on trust three analyses evaluated framing effects on trust in the robot using a similar logic and covariates as with rq2 1 ancova compared trustworthiness evaluations across groundrule groups 2 mancova compared physical relational and conversational distance scores and 3 chisquare testing considered differences in explicit binary trust ascription analysis demonstrated no framing effects on trustworthiness 079 p 0531 part η 2 0008 or social distance 083 p 0616 again whether participants individual frames matched our produced frames had no significant effect on trustworthiness 108 p 0299 part η 2 0003 or social distance 240 p 0067 see supplements for detailed results for individual frames similarly participants did not vary significantly in explicit trust ascription 599 p 0200 cramérs v 0121 answering rq3 groundrule primes prompted no framing effects on social robottrust indicators study 3 explanatory frame effects on judgments of a copresent robot although survey procedures leveraging video stimuli have the benefit of efficiently recruiting large samples extant evidence indicates that mediated presentations of robots garner different social and moral evaluations compared to inperson exposures because robots are physical embodiments of ai study 2 was replicated in a facetoface setting to determine whether copresence may differently foster framing effects procedure and stimulus event procedures followed those in study 2 with adaptations for inperson robot stimuli a convenience sample of us college students were invited to participate in a study on feelings about robots in different situations and offered course credit and us5 for their participation they first completed an online survey and then visited a research lab to complete an inperson protocol each lab session accommodated up to six participants all sitting facing the robot visually and physically separated by black dividers to avoid distraction or social influence the robot was obscured until the session began a session moderator guided participants through the protocol first introducing ray and asking her tell our guests a bit about yourself to which ray offered an introduction identical to that in study 2 then the moderator asked ray to talk generally about how she interacts with people and then specifically asked whether she has a guiding principle or world view to determine how to act ray responded verbally with one of the five groundruleframing primes the frame condition was randomly assigned at the session level the moderator then introduced the main activity hearing about rays experiences interacting with humans mirroring study 2 seven scenario prompts and responses followed in a random order and goodnessbadness and responsibility ratings were completed on a tablet computer immediately after each scenario after all scenarios ray was again obscured and participants completed a followup survey with morality and trust judgments identical to those in the second study in contrast to study 2 a more conservative approach to validating the manipulation was employed capturing the individual frame interpretation at the end of the procedure to determine whether the framepriming persisted throughout the behavior evaluations measures all measures were identical to those in study 2 inclusive of dependent variables for moral judgments and trustworthiness capacity trust m 518 results to again examine degree of frame divergence the produced and individual explanatory frames were compared only about half of participants individual frames matched the produced groundrule framing so a covariate reflecting whether participants individual frames matched given produced frames was again included in analyses framing effects on moral judgments planned analyses were to parallel those in study 2 however mancova for goodness ratings was performed only for scenarios with widely consistent and moderate interitem correlations careharm fairnesscheating and authoritysubversion ancovas were performed for the remaining scenarios which had mostly weak mutual correlations interitem correlations of responsibility were consistently moderate to high so mancova was preferred covariates were identical to those in study 1 goodness ratings did not vary across framing conditions for careharm fairnesscheating and authoritysubversion scenarios 081 p 0637 nor in any univariate analysis 071135 ps 02610589 part η 2 00430079 no multivariate effect was found for participants attribution of responsibility 109 p 0358 table 4 however univariate analyses considering domainspecific impacts revealed a significant effect in the libertyoppression scenario 288 p 0030 part η 2 0154 participants in the normal condition attributed less responsibility to ray than those in other conditions although post hoc tukeys tests did not show significant differences we do interpret them here given the small sample size in tandem with the large effect size regarding rq2 findings diverged from study 2 in which the produced frame did impact a domainspecific responsibility judgment however results further indicate a scarcity of effects by explanatory frames no multivariate or univariate effects were found for participants match between individual and produced frames on goodness ratings 097 p 0412 and fs 0001201 ps 01620986 part η 2 0031 nor a multivariate effect on responsibility ratings 134 p 0251 see supplements for exploratory analyses of mis matching indicators framing effects on trust analyses were similar to those in study 2 separate mancovas comparing a capacity and moral trustworthiness and physical relational and conversational distance across groundrule frame groups a chisquare test compared binary trust ascription across groups no multivariate framing effects were found on capacity and moral trustworthiness f 289 p 0042 univariate analysis revealed this multivariate effect was mainly driven by physical distance 1037 p 0016 part η 2 0089 participants whose individual framing did not match the produced frame preferred a higher physical distance to ray than participants for whom the framings matched participants did not differ in explicit trust ascription 587 p 0209 v 0278 in line with study 2 for rq3 there were no framing effects on a social robots perceived trustworthiness but producedindividual frame mismatch corresponds with preference for greater physical distance general discussion the present investigation into individual and produced frames for explaining social robot behavior induced five explanatory frames advance the self advance others do what is good do what is logical and do what is normal however priming these frames had limited effects on morality and trust judgments of a social robot engaging in morally ambiguous behavior when the robot was presented through video there were no significant framing effects and no apparent influence of whether the individual frame matched the produced frame when the robot was copresent effects were also limited but with some theoretically relevant deviations specifically when explaining libertyoppressionrelated behavior using a norm frame the robot was assigned less responsibility for behaviors than when the robot used other explanatory frames additionally although there was no significant impact of frame on trust in the robot those whose individual frames deviated from the produced frame expressed preference to remain more physically distant from the robot overall these findings are interpreted to suggest that a robots expressed frames explaining its behavior have little effect on moral and trust judgments and the limited effects are functions of attributional heuristics and reactance norm frames drive shorthand behavior judgment a do what is normal explanatory frame for robot behavior manifested an effect on responsibility judgmentsbut only narrowly in the libertyoppression scenario acknowledging that this is a remarkably narrow set of boundary conditions it is nonetheless useful to explore since adherence to social norms are argued to be a necessary condition for the integration of robots into human social spheres notably normalcy is a relatively abstract notion in comparison to the more specific egoistic altruistic and logic frames this abstraction may have promoted heuristic processing in ways that afforded fastandfrugal assessment of behaviors where normalcy may be shorthandedly processed as morally reasonable through ease of processing common notions people often rely on moral rules to make judgments and enact behaviors but those rules are contextsensitive such that a norm frame can initiate domainspecific effects as a function of what counts as contextually and socially normal behavior here regarding descriptive norms a general prime of normalcy may have anchored the interpretation of the ambiguous behavior as necessarily norm compliant the norm frame and the specific stimulus scenarios may have aligned in ways that allowed for highly accessible interpretations so observers committed frugal interpretations moreover that positive effects of the normal frame emerged only with inperson encounters and a local population indicate that normfocused explanatory frames may only prompt grounded evaluations when the social robot and human share a context and where the moral norms are cohesive limitation of the effect to the liberty oppression scenario may be a function of local politics of the copresent study data were collected at a west texas university such that the regions high valuation of rugged individualism may have coordinated similar notions of normalcy for that foundation this ostensible heuristic processing notably does not necessarily represent shallow or lazy thinking rather people tend to rely on fuzzy gistbased intuition in reasoning generally and this tendency is exacerbated for moral reasoning about protected values fear and resistance to produced frames importantly many participants individual frames did not correspond discretely to the produced frames delivered by the robot this mismatching did not correspond significantly to moral judgments for either study or to trust judgments of the mediated robot however mismatching corresponded significantly to a trust indicatorpreferred physical distancefor the copresent robot those with mismatched producedindividual frames reported a preference for maintaining greater physical distance from the robot compared to those with matched frames in tandem those with mismatched frames also had higher average technophobia scores than those with matched frames the fact that these associations appeared only for the copresent robot suggests thatwhen sharing a physical space with a robotpeople who were already skeptical about modern technologies may experience reactance they desire to resolve they prefer to distance themselves physically from the machine and resist the robots produced frame in favor of a divergent individual frame this finding has important implications for the utility of robotproduced frames in xai that suggests that for technophobic human interactants a certain uneasiness would first need to be mitigated before the human would actually engage a robotproduced explanatory frame for its behaviors this is especially important for realworld hri implementations in which the physical copresence of the robot may be a trigger for producedframe resistance lack of other framing effects impacts of individual frames as noted framing effects were limited to norm frames impacting responsibility judgments for the libertyoppression scenario there are several potential drivers for this scarcity in other significant effects most simply the manipulations were based on the induction of individually held frames that may not have functioned well as priming frames or may have been too weak an inductive to prompt identifiable patterns in a worst case that could mean that any significant results that we found emerged solely due to chance rather than from framing alternately participants individually held framesthe global or local ideologies brought into experiencesmay have been more impactful than the robotpresented frames this possibility aligns with the primacy of effects from individual frames over produced frames indeed people have predispositions toward anthropomorphic or mechanistic interpretations of robot behaviors such that the brief and agentspecific frames may have carried little weight in the face of enduring individual frames the robot may not have been seen as a credible source for explanations of its own behavior as people often consider an absentbutconspicuous programmer in evaluating a robots actions perhaps then message frames alone do not elicit a judgment as people process those messages in relation to complementary individual frames and immediate contexts to form impressions of moral events limitations and future research the present investigation carries limitations inherent to study designs which should be addressed in future research the usual suspects are at play however we have worked to mitigate those by constellating the three studies each compensating for others weaknesses it must be acknowledged that where significant findings emerged participants assessments for goodness hovered about the scale midpoint such that on the spectrum from badtogood the means were effectively middling this is expected given that stimuli were purposefully ambiguous so even small differences are still meaningful deviations from neutral positions moreover middling means may further support an interpretation of frugal processing as participants may have similarly engaged in attribute substitution or the tendency to substitute a simpler problem for a complicated problem as is always the case the choice of measurements may also impact study findings in particular we asked for an assessment of the robots responsibility for their action however the notion of responsibility may be asymmetrically applied to good and bad behaviors and as a humanistic frame for moral agency may be variably interpreted with respect to robots future work may investigate these dynamics as argued interpretation of events may be impacted by both produced and individual frames individual frames are complex mental models constellated from various sources over time while produced frames in the present study were delivered once briefly from a novel robot because the current framing manipulation was a shortterm prime it is possible that effects could fall away or new ones could emerge over time humanrobot interaction is known to be impacted by novelty effects such that interest or anxiety regarding the novel encounter could have overridden other possible effects or perhaps the robots framing behavior must be reinforced with interstitial corresponding behavior presenting participants with a series of seven moral situations to evaluate may have enhanced the perceived artificiality of the scenarios such that early framing effects may have been vanished with repeated measurements indeed exploratory analyses of the first scenarios provide partial support for this assumption notably however framing effects can persist over time such that practical questions of dosage for a norm frame emerge as a fruitful path for future research how much and how often should a robot deliver a behaviorexplanation frame in order for it to retain its impacts on judgments finally we have argued for the importance of robotpresented frames in the xai movement in terms of the induced groundrule frames abilities to bridge the anthropomorphic and mechanistic sides of that debate although these frames had limited impact on moral and trust judgments they hold potential for fostering authentic understandings of robot behavioral mechanics in terms of their logics while those logics are abstract enough to have social meaning in everyday life in a sense the explanatory frames conveying operating ground rules may function as boundary objects rules that are plastic enough to adapt to local needs and constraints yet robust enough to maintain a common identity across site they are weakly structured in common use and become strongly structured in individualsite use the potentials for ground rules to productively impact a balance between mechanistic literacy around and anthropomorphic acceptance of social robots should be further explored further the present investigation examined framing of only a single robotan androidand social and functional robots of other morphologies could evoke different mental models that require different degrees or types of literacies these potentials require further investigation similarly we acknowledge that presenting ray as female might have provided participants with visual cueing and linguistic preconstruction of their relationship with it it is possible that nongendered agent presentations might elicit varying responses conclusion as embodied ai becomes increasingly prevalent in contemporary society its behaviors framing by media and by its own presentations will also gain importanceboth for whether it is accepted and for how its functioning is understood these studies exhibit discernible patterns in individuals frames for robotbehavior explanationsrules pertaining to self other logic goodness and norms norm frames may have limited effects on robot responsibility judgments likely through the activation of fastandfrugal heuristic processing perhaps most importantly findings suggest that people fearful of robots may resist produced frames and instead activate their own explanations for robot behavior findings have important implications for xai processes and effects a norm frame may provoke lower perceptions of robots responsibility for its own behavior while exogenous technophobia may promote more subjective interpretations of behavior drives that deviate from attempts to promote authentic understandings of robot functioning the potential for these explanatory frames to bridge the gap between anthropomorphic and mechanistic explanations for robot behavior should be further explored for their beneficial and detrimental impacts on acceptance and understanding stimulus materials the social robot used in this study was the same as in study 1 it was similarly called ray and presented as female all stimulus videos were embedded in the survey interface data availability statement the datasets presented in this study can be found in online repositories the names of the repositoryrepositories and accession number can be found below ethics statement the studies involving human participants were reviewed and approved by the texas tech university human research protection program written informed consent for participation was not required for studies 1 and 2 in accordance with the national legislation and the institutional requirements the participants provided their written informed consent to participate in study 3 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

framesdiscursive structures that make dimensions of a situation more or less salientare understood to influence how people understand novel technologies as technological agents are increasingly integrated into society it becomes important to discover how native understandings ie individual frames of social robots are associated with how they are characterized by media technology developers and even the agents themselves ie produced frames moreover these individual and produced frames may influence the ways in which people see social robots as legitimate and trustworthy agentsespecially in the face of im moral behavior this threestudy investigation begins to address this knowledge gap by 1 identifying individually held frames for explaining an androids im moral behavior and experimentally testing how produced frames prime judgments about an androids morally ambiguous behavior in 2 mediated representations and 3 facetoface exposures results indicate that people rely on discernible ground rules to explain social robot behaviors these frames induced only limited effects on responsibility judgments of that robots morally ambiguous behavior evidence also suggests that technophobiainduced reactance may move people to reject a produced frame in favor of a divergent individual frame

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what we already know social stigma against persons infected with coronavirus disease and their family members resulting from public fear about this newly emerged infectious disease is not uncommon the affected group have been blamed for contracting the disease but refraining from seeking medical care to avoid social stigma and discrimination social stigma could negatively impact the emotional mental and physical wellbeing of the persons recovered from covid19 as well as their family members introduction coronavirus disease is a newly emerged infectious disease resulting from the persontoperson spreading of severe acute respiratory syndrome coronavirus 2 1 one of the impacts in the context of health is social stigma against people who have contracted covid19 social stigma is defined as negative association related to a person or a group of people or places sharing certain characteristics or specific disease 2 3 4 5 stigma could affect the emotion mental and physical wellbeing of the inflicted groups stigmatized people attributed to infectious diseases may experience rejections from partners families friends dismissal from work and declined quality of health services received causing alienation depression or anxiety 6 7 8 while there were limited studies related to social stigma among individual inflicted by covid19 their experience could possibly be similar to the persons affected by infectious disease such as hivaids and tuberculosis these patients and people living with them often experience social stigma such as discrimination devaluation stereotyping isolation discrediting prejudice humiliation or aggressive attitude 59 in a study conducted by kumar et al in india it was found that among the 104 study respondents living with hiv aids more than half of them experienced stigma 10 similarly about 50 of study population in nigeria had discriminated hivinfected patients and persons caring for them and perceived that this population should be blamed for bringing the disease into the community 11 the family members of the affected patients especially spouses who had lower educational levels may experience higher level of depression anxiety and stress due to the stigmatization 12 in china more than two third of the family members living with hiv patients anticipated stigmatization from their social network 13 in the united states hiv caregivingrelated stigma and nondisclosure of caregiving status was associated with more depressive symptoms among the family members 14 in malaysia hiv aidsrelated stigma was prevalent among the general public in malaysia the public perceived that they will be isolated by the community feel ashamed and will not disclose to others if someone among their family members contracted this infectious disease this is was mainly due to fear of the lethal and contagion nature of hiv infection 15 stigmatized persons are often associated with nondisclosure of disease status 16 avoidance of medical care and nonadherence to treatment to avoid discrimination 1718 this may severely disrupt the efforts to manage any infectious disease outbreak 16 in south africa 80 of the 400 patients with hiv did not feel comfortable to disclose their status 19 meanwhile the majority of hivaids patients in malaysia also choose not disclose their disease whereby their choice is attributed to fear of stigma and discrimination social consequences and affecting their family emotions negatively 20 the issue of nondisclosure was commonly reported during the outbreak of covid19 and the reasons for this could possibly be similar to the social stigma associated with other infectious diseases including leprosy influenza or severe acute respiratory syndrome 1621 those who developed symptoms of covid19 or had close contact with covid19 patients may hide their contact history and progress to a more severe stage this may also cause ongoing transmission and difficulties in controlling infectious diseases during an infectious disease outbreak 22 the malaysian government advised the people not to hide their medical and travel history from health care workers as this may pose significant risk of infecting the latter 23 destigmatization of infectious diseases is hence important to reduce the rate of nondisclosure and transmission and reduce discrimination with improvement in disease awareness among the general population 20 given the severity of healthrelated outcomes resulting from stigmatization this study aimed to explore the experience of patients and their family members in regards to covid19 related social stigma and their suggestions to mitigate this problem which could serve as an important input for developing strategies to reduce stigmatization method researchers aim to understand how the patients and their family members perceive their personal experience of contracting covid19 disease in the context of stigmatization hence a phenomenological approach was used this approach allows participants to tell describe and articulate their stories in depth with greater details as they have had lived through with the covid19 diseaserelated experience 24 this guided the researchers in drafting the topic guide for the interview the domains include participants perspective and understanding of covid19 their experience before the patients admitted to the hospital during their hospitalization and after their discharge their intention of disclosure support they needed and suggestions to mitigate stigma this was a qualitative study conducted via telephone interview between april and june 2020 at a tertiary covid19 referral hospital in the state of perak in malaysia the purposive sampling technique was employed to recruit participants in this study 24 participants were categorized into patients and family members patients with malaysian nationality tested positive for covid19 aged ranging from 18 to 65 years old recovered and discharged home for at least 1 month were included in this study the inclusion criteria for the patients family members were those with malaysian nationality who were tested negative for covid19 between 18 and 65 years old have been residing with the patients for at least once a week to provide care and support on a regular basis there is no clear definition of family involvement in residential longterm care however most of the study findings have indicated that up to 70 of family members visited their loved one on weekly basis 2526 it is deemed that family members who stayed close to the patients have a higher chance of experiencing the stigmatization those who were unable to speak or understand malay english or mandarin language and have intellectual impairment were excluded from this study the initial estimated sample size was 10 participants each from the category of patients and the family members the actual sample size was determined by the point of themes saturation 27 a semistructure interview guide was developed based on the published literatures 10 11 12 13 14 15 and reviewed by the research team a senior academician four clinical researchers and the hospital deputy director forward and backward translation of english version to malay and mandarin version were conducted by a bilingual researcher ethics clearance was obtained from the malaysian medical research ethics committee reference no kkmnihsec p20939 prior to data collection the procedure to obtain verbal consent was approved by the ethics committee prior to conducting this study and all participants who agreed to participate were consented in the process of obtaining informed consent the content in the participant information sheet were completely conveyed to the participants verbally they were informed that a copy of the participant information sheet can be posted or emailed to them should they require one however none of them had asked for a copy of this information sheet this study was conducted in accordance with the malaysian nih guidelines for conducting research in the moh institutions facilities 28 potential participants were identified through the medical records office and they were contacted through telephone calls by an interviewer the interviewer is a medical doctor with 10 years of practice and 3 years of clinical research experience she was not involved in the treatment of the patients with covid19 and did not know the participants in person all patients were recruited using cold call method 29 patients were then asked to recommend a family member who stayed in the same household to participate in this study the participants were briefed regarding the aims and purposes of this study using the participant information sheet an indepth onetoone interview with the participants was conducted via telephone call and the conversation was audio recorded the participants were allowed to select their preferred language and time for the interview each interview took 30 min on average all the audiorecordings were transcribed verbatim by two researchers at the end of each interview session the interviews conducted in the malay language were subsequently translated into the english language by the same researchers the data were managed using microsoft® 365 excel and analyzed via thematic analysis ctc and ccc were involved in developing code book by performing linebyline open coding individually the codes generated were then compiled the codes were then finetuned to generate descriptive themes themes generated were constantly compared with the data to confirm the end point of data saturations the end point was reached when the data collected were sufficient to account for the emerging themes 2430 at the 12th patients and the 6th family members there were no more new themes emerged saturation point was reached and the interview stopped with a final sample size of 18 participants a consensus on the theme and subtheme generated were reached among the researchers results out of 93 telephone call attempts 20 answered the calls and two patients declined participation due to busy schedules the median age of patients was 365 years old and family members was 560 the duration of admission ranged from 10 to 16 days most of the participants had tertiary education professional occupation and married the family members were having at least secondary educational level most were homemakers and all married see table 1 characteristics of participants a total of three themes and 11 subthemes emerged from the interviews theme ι experiences of stigmatization experience of stigmatization among participants began when they were suspected of contracting the disease and then treated as infective after recovering from the disease some family members who were diseasefree have also been treated unfairly isolation most of the participants felt isolated primarily because of the behavior of the health care professionals once they were suspected of infection they were handled as covid19 positive even without laboratory test results i felt offended when i was treated as if i had been tested positive for covid19 initially on march 17 they did not act as if the situation was serious but i had to take food from the outside i could really see that they didnt come to my room and they just contacted me through phone the sample was taken on march 19 and then on march 23 they came back and took another sample they did not return to my room since then once they even failed to offer me tea so i had to call to say i didnt have tea they apologized for overlooking my room because my room was too far away at first i felt insulted i had to express my needs whenever i had to change i had to ask for clothes etc and they left the clothes at the door without entering the room i havent even tested positive yet if they want to wear ppe they can just wear it i dont mind but they put the clothes on the side of the door as if im seriously sick with the virus isolation by the health care providers happened even after the patients recovered from the infectious disease this phenomenon has mainly occurred in a government tertiary hospital when participants went to seek medical care as i see that everyone was fearful the nurse was terrified the doctors were afraid the nurse who checked my temperature and blood pressure was not happy but i can understand then i said why are you scared i have already recovered i am even more scared she was scared and she was sitting far away from me she didnt want to be with me for long she didnt even want to talk to me some of the recovered participants felt socially isolated because the people around them were trying to keep a distance a few participants noticed that those suspected but not confirmed covid19 positive were also isolated by the neighborhood they were isolating us they isolate us as i have heard that previously there was a suspected case not confirmed positive or negative yet when the villagers know everyone has already started to stay away from him fear of staying closer and yet not positive there was no case at the same location labelling some of the patients family members expressed that they were being labelled as covid19 by the neighbors even after recovery yes in the end the neighbor were fine not that worried but we are still being labelled as covid19 participants who recovered from the disease were still treated as covid19 positive patients by the civil servants i told him that i was once covid19 positive but now its already negative then he said it was all a few participants felt offended when their family members were treated unfairly by their neighbors at first i was angry when the neighbor told her children who were playing outside the house to go home early once she saw my mother hang drying the laundry my mother felt insulted over this event blame some of the recovered participants were blamed by the health care providers for spreading the disease that doctor scolded me oh youve just returned to your hometown of penang for your own sake i was wondering my purpose was to visit my family and i never expected to get sick and yet he scolded me theme ιι perspectives on disease disclosure the willingness of the participants to disclose their history of covid19 varied from willing to disclose freely disclosure upon official purposes and refusal to disclose willing to disclose freely some of them were willing to tell others about their history as they felt the need to share the experiences with others and to stop the chain of this infectious disease sure im going to reveal as we had experience so were going to share that there was no reason to keep this as a secret yes i am going to tell that i was positive once and they are going to know about this history too the decision to disclose this history was mainly with the aim of breaking the chain selective disclosure the disclosure of being covid19 positive was restricted only for official purpose as the participants were worried that the public or the shopkeepers would be in fear if they revealed their encounter history im going to reveal it if its for official purpose however if we were to tell the neighbors or when we go for shopping theyll be scared and wont let us go to the store we have been rid of this disease for months wed tell our friends if it was necessary if not wed just smile at them most of recovered participants admitted that they will not disclose their medical history mainly because of fear and lack of understanding among the public i prefer to conceal when given a choice as it is very difficult to control other peoples perception and they were fear of covid19 when their understanding is very shallow instead of explaining to them we should just keep them in the dark theme ιιι suggestions to reduce stigmatization supports by the government the participants suggested that the relevant government departments should provide assurance to the public that patients recovered from the disease are not contagious to others they may be terrified of us even though we are already negative we have a high probability of respreading the disease which means the virus could be reactivated the society is very concerned about this and their responses are very important to us to me moh or mkn should provide details where we as covid patients former covid patients will not be contagious or will not spread the disease and others will not be affected by the former covid patient this means that workers can return to work without any problems as they have recovered from the illness in addition some of the participants wanted to file complaints about the issue of isolation but they were not sure which government agency they should complain to i would like to make a complaint if there were people who isolated us to whom or to which department i should address my complaint to the society and public while the issues of isolation were common among participants most of them asserted that they should be treated equally by the public and not by staying away from them should not stay away from us i want to ask them if people do this to you because you have an illness what are your feelings we have to take care of peoples feelings this wasnt just about us it was about others too some of the recovered participants felt that they need to spend more time sharing their experience with the public about disease contact its effect hospital stay and the consequences of not practicing preventive measures when they were asked about methods to reduce stigma we need to spend more time talking to people and let them know how we get infected with the disease what are the symptoms what are the conditions in the hospital we should let them know that if we did not take care of our own wellbeing practice social distancing and the risks would have escalated colleagues support one of the recovered participants hoped to maintain an interpersonal relationship and a cheerful place of work just like before the pandemic if possible work as before covid19 if it is possible to create a warmth of human relationships just as before covid19 like a happy friendly environment and now all this has been diminished i understand the safety measures at work in which we cant get together and have to be alone we all understand that health care providers support most of them suggested that patient counselling was important to help them cope with this period the followup telephone calls by public hospital psychiatrists were deemed helpful to check on the patients condition may be through emotional like what they are doing now the government psychiatrist they can call check on them because some may have gone really bad depression you know all dont cope it same way right maybe some was really down until depression and all so maybe the psychiatrist doctor can help them out by calling them and asking them about their condition i think they already started doing that it could be through emotional support as they do government psychiatrists may call to check on them because some of them were depressed you know we dont all behave the same way some were depressed and psychiatrists can help by calling them and asking about their conditions i think they have already started of doing this the participants felt that counselor may be needed for hospital staff who did not contract the disease and that they should be exposed with knowledge on the prevention of stigmatization against persons tested positive for covid19 need to involve counselor i think … counselor can offer some guidance to workers who are not covid positive how to prevent stigma for instance people surrounding have to behave normally when interacting with the discharged person the recovered person might feel weird when everyone gets to know about covid positive and quarantines some of my colleagues who were tested negative were quarantined too they were being teased by my other colleagues for getting 14 days of free leaves they told me that they were not asking for it they were suffering during quarantine and others who were otherwise healthy have to work more frequent shift especially night duty some of them believe that counselling from counsellor was important to some patients the counselling service is perceived as a channel for patients to ask for more information and to receive care from health care providers counseling is essential but i know it is not for everyone as some may need helps from people outside the hospital for me ive been good without any support many people could never cope without support they need help and care such as love sometimes we dont know that patients have other issues many of them will not be able to cope and they would be depressed it would be better if counselling service is available which we can ask for advice i think that should show their concern and id like some people care about me too religious support participants suggested that a religious teacher would be helpful in coping with a stressful period he the ustaz may help by supporting those of us who are muslims sometimes we say a predestined test and the ustaz may help spiritually if anyone is stressed out discussion this is the first research in the malaysian context to the best of our knowledge describing the stigmatization experiences of patients with covid19 and their family members experience from the time they were suspected of having the disease seeking care at the hospital until the patient recovered from the disease were explored in the malaysian context this study outlined the views of the participants on the experience of stigma and their willingness to disclose their illness the feedback on how to minimize stigma is a valuable knowledge for health policy makers in designing policies to combat stigma and support societies recovery from this pandemic 31 the experiences of the participants who were isolated labelled and blamed for having covid19 were similar to those affected by hiv aids and tuberculosis as well as the outbreak of sars in 2003 such stigma has been correlated with negative impacts particularly on mental health and has already become a prominent public health problem 8111521 of concern patients reported being blamed by health care providers and their suggestions to improve the awareness of healthcare workers on the prevention of stigma imply the problem of stigma in health facilities stigma in health facilities is not uncommon and is often associated with denial of care provision of substandard care physical and verbal abuse by health care providers 32 in line with the participants suggestion teaching the health care providers about stigma its manifestations and effect on patients health were measures to reduce stigma developing the skills of health care providers to work with stigmatized group engaging them to be in contact with the stigmatized group while delivering intervention to mitigate stigma and empowering the stigmatized group to improve coping mechanism were approaches in overcoming stigma at health facilities 32 some participants preferred to keep their history of covid19 confidential the reasons for the nondisclosure of the medical history were consistent with the perspective of patients with infectious diseases including leprosy and hiv aids mainly due to insufficient knowledge and concern about contagious nature of the disease among the public 2161820 covid19 a highly contagious and new infectious disease with many unknown areas may be a leading source of public misconceptions and misinformation which are the key contributor to stigma 233 another reason for their nondisclosure is the concern over the possibility to be banned from carrying out routine tasks such as purchasing groceries and these concerns were similar to those in the previous study 20 public understanding and compassion are important in reducing stigma 1134 as some participants have suggested earlier lack of knowledge and misinformation of the infectious diseases are contributing factors to stigma 2313335 reliable information on disease prevention treatment options accessibility of health care in plain language should be disseminated in social media by governments the communities media and key influencer as potential methods for combating stigma 23336 to keep the public abreast of the covid19 situation in malaysia the ministry of health malaysia produced daily press statement and press conferences covering statistics of the recovered covid19 cases number of newly confirmed case number of confirmed cases by states and new death cases apart from the disease statistics health advisory were regularly disseminated including important preventive measures such as the 3c to avoid crowded places confined spaces and close conversations 37 based on our findings information on social stigmatization towards the public is important to reduce its occurrence in india the ministry of health and family welfare has advised the public not to blame the covid19 patients provide support to the patients and family members and not to disclose the names or identity of those affected or under quarantine on the social media 38 the japan educational ministry has warned the education boards over the country to stop discrimination and prejudice against workers exposed to higher risks of contracting the novel coronavirus 39 it is noteworthy that the mohm has recently added the mental health and psychosocial aspect in covid19 to inform the public on the dos and donts when interacting with covid19 patients or their family members 34 interventions to mitigate infectious diseaserelated stigma often involving multifaceted approaches and requiring the collaboration of stakeholders from different fields including the government health care providers the public and key opinion leaders 2 the ministry of health malaysia is aware of the importance of stigma associated mental health problem among covid19 patients stigma reduction was advocated as one of the interventions for mental health support to the affected person the general public and health care workers were recommended not to define the affected persons as covid19 and support them with mental and psychological support 34 in the guide to prevent and addressing stigma who urged the authorities and media to share sympathetic narratives that humanize the experiences and struggles of the infected patients or family members 2 as of june 2020 malaysia has reported a total positive covid19 cases of more than 8000 37 the authorities and media may consider inviting patients to share their experience of stigmatization after sufficiently anonymizing their identity such interventions were consistent with the suggestions made by some of the participants in this research who were willing to share their experience of exposure diagnosis and their perceived stigmatization experience in the community as reported in a previous study the dissemination of digital stories using social media may be a feasible way to educate the public reducing fear and anxiety among the affected communities 40 various interventions have been found effective to reduce stigmatization by the healthcare providers towards their patients 32 it was previously reported that a stigma reduction educational session targeting health providers may improve their attitude and reduce stigmatization among hiv patients 40 in china the stigma reduction program implemented to disseminate stigma reduction messages by popular opinion leaders to other healthcare providers was found to be effective 41 a multifaceted approach with the establishment of hospital steering committees staff training using a stigmatization awareness module and hospital policy development could effectively reduce stigmatization towards hiv patients 42 the mohm has developed a comprehensive guidelines of covid19 management in malaysia which covered the clinical management of covid19 cases sampling procedure methods for social distancing etc 43 the ministry guideline also contained the message to reduce personal identification of patients with covid19 but recognized them as people who are recovering from covid19 34 while a targeted educational approach may be the most effective way to reduce stigmatization familiarization and training of healthcare providers with the existing mohm guidelines may be practical with the current limited resources there were several limitations in this study the findings from our single center study cannot be generalized to other health institutions the study was conducted during the countrys movement control order lockdown period where most of the work and social activities of the participants remained restricted and the experience of stigmatization after being discharged from the hospital cannot be described in full context future researches could consider exploring the knowledge level and belief about this disease among the public to identify the knowledge gap and misinformation which in turn would help to address the social stigma issue 33 conclusion individuals recovered from covid19 and their families experienced stigma including labelling isolation and blamed for contracting the disease fear and lack of public understanding of the covid19 disease were the key factors for nondisclosure nevertheless some recovered patients were willing to share their experience as a way to increase public awareness on negative impacts of stigmatization and thereby helping to reduce stigma the government the general public healthcare professionals and religious leaders played important roles in the efforts to reduce social stigma issues authors contributions ccc ctc and wyl developed study proposal analyzed the data and wrote the report xjl collected the data analyzed the data and wrote the report pr generated the research topic supervised and proofread the report nn provided administrative support identified potential participants all authors read and approved the final report for publication funding the research received no specific grant from any funding agency in the public commercial or notforprofit sectors competing interests the authors declare that there is no conflict of interest

background social stigma against persons infected with covid19 is not uncommon this qualitative study aimed to explore the experience of social stigma among covid19 positive patients and their family members method this crosssectional study was conducted between april to june 2020 in malaysia patients who have recovered from covid19 for at least 1 month and their family members who were tested with negative results malaysian and aged 1865 years old were purposively sampled cold call method was employed to recruit patients while their family members were recruited by their recommendations telephone interviews were conducted with the participants after obtaining their verbal consent results a total of 18 participants took part in this study three themes emerged from the interviews ι experience of stigmatization ιι perspective on disease disclosure and ιιι suggestion on coping and reducing stigma the participants expressed their experiences of being isolated labelled and blamed by the people surrounding them including the health care providers neighbours and staff at the service counters some respondents expressed their willingness to share their experience with others by emphasizing the importance of taking preventive measure in order to stop the chain of virus transmission and some of them chose to disclose this medical history for official purpose because of fear and lack of understanding among the public as suggested by the respondents the approaches in addressing social stigma require the involvement of the government the public health care provider and religious leaderindividuals recovered from covid19 and their families experienced social stigma fear and lack of public understanding of the covid19 disease were the key factors for nondisclosure some expressed their willingness to share their experience as they perceived it as method to increase public awareness and thereby reducing social stigma multifaceted approaches with the involvement of multiple parties including the government nongovernmental organization as well as the general public were recommended as important measures to address the issues of social stigma

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introduction alcohol consumption is responsible for 3 million deaths per year worldwide it is the prime preventable risk factor for death and disability among 1549yearolds 1 according to the who europe is the region with the highest alcohol consumption 2 in france the level of alcohol consumption remains high 3 according to the french national public health agency 236 of people aged 18 to 75 exceed the accepted consumption guidelines and alcohol was responsible for 41000 deaths in france in 2017 4 alcohol consumption could evolve according to environmental factors for instance with the recent environmental changes resulting from the pandemic the sarscov2 epidemic appeared in late 2019 in china in wuhan before spreading worldwide on 11 march 2020 the who reclassified the epidemic as a pandemic then termed covid19 5 in order to stop the exponential spread of the virus and to preserve the healthcare system the french government implemented unprecedented measures to limit social interactions among individuals which disrupted the daily life of the french population two main lockdown periods were decided the first in spring 2020 during which all nonessential businesses bars and restaurants were closed as were schools and the population was required to stay at home with restrictions on movement during the second lockdown from 30 october 2020 to 15 december 2020 schools remained open and it was possible for some people to go to work but the other measures were similar these two successive waves raised fears of a third wave in the form of an epidemic of psychological disorders in the population 6 restaurants and social venues where alcohol consumption was possible were closed and social gatherings were severely restricted during these periods but alcohol was still widely available in supermarkets so home consumption became a concern among the main motivations for alcohol consumption the need to counteract depressive affects or stress is prominent and many studies have shown that the cooccurrence of these disorders potentiates the negative effects in terms of prognosis 7 8 9 10 in a vicious circle it is feared that the climate of anxiety could mechanically increase the factors favoring alcohol consumption existing studies exploring the initial impact of the covid19 pandemic on alcohol consumption in the general population present conflicting results some studies suggest that more people increased their alcohol consumption than reduced it 1112 this increase could be seen as a coping strategy to manage psychological distress however other studies in contrast indicate that alcohol consumption may have decreased at the population level during the first months of the covid19 pandemic 1314 according to these results the restriction of access to the usual places of alcohol consumption as well as the reduced affordability as a result of increased unemployment and financial insecurity could have led to a reduction in the levels of alcohol consumption in the general population 1516 a recent metaanalysis published by kilian et al 17 suggested that during the first months of the covid19 pandemic the number of people who reduced their alcohol consumption in europe was greater than the number of people who increased their consumption concerning the evolution in france guignard et al reported that during the first lockdown 107 of the respondents reported having increased their alcohol consumption and 244 reported having decreased it 18 to our knowledge few longerterm studies have been conducted in france to explore the evolution of alcohol consumption levels during the pandemic consequently the objective of this study was to evaluate the evolution of alcohol consumption 1 year after the onset of the covid19 pandemic in a region of france and to determine the factors associated with an increase or decrease in alcohol consumption materials and methods study designsample a crosssectional study was conducted in the general population this study used an online selfadministered questionnaire this questionnaire was developed by the studys scientific committee which included doctors specializing in addictive disorders general practitioners and methodologists the questionnaire was first tested on a small sample of people to make sure that the questions were well understood and that the process and time needed to complete it were acceptable circulation of the questionnaire the inclusion criteria were being aged over 18 years command of the french language and consent to participate as the intention was to target the adult general population only underage participants were excluded the questionnaire was widely disseminated to the general population through several media either email lists with a link to the study or using a qr code which was linked to the questionnaire we obtained agreement from the brest university hospital authorities the city of brest and the university to disseminate the questionnaire to employees via their mailing lists the study was disseminated through the press and on the internet it was also disseminated through posters which were distributed in general practitioners offices finally in order to gain access to a larger number of people in precarious situations who do not have internet access the questionnaire was distributed in paper form to the social services network of the city of brest participants who were included were those who completed the questionnaires between 18 january and 9 march 2021 there were no inclusion or noninclusion criteria this was a general population observational study relying on the willingness of participants to respond description of variables and measures sociodemographic variables the sociodemographic variables collected were gender age place of residence living conditions and socioprofessional category a specific distinction was made between respondents working as health professionals and others we also collected recent socioprofessional status changes during the pandemic and lockdowns medical and psychiatric history we explored the history of health disorders respondents were asked if they had a history of medical or surgical disorders or chronic illness or psychiatric or addictive disorders they were also asked if more particularly during the pandemic they had experienced medicalsurgical or psychiatric disorders and if they had been affected by covid19 in any way main outcome changes in alcohol consumption we explored reported alcohol consumption before during and after lockdowns the questions were all worded to focus on any evolution in consumption with the pandemic and lockdowns the auditc questionnaire was used to assess alcohol consumption in this questionnaire three variables are assessed frequency of alcohol consumption number of drinks per day and frequency of heavy drinking responses to each item are rated from 0 to 4 the auditc score was calculated for each participant by summing the responses to the three variables listed above the score ranges from 0 to 12 in men a score of 4 or more was considered positive in women a score of 3 or more was considered positive the auditc score was then categorized into three levels lowrisk use for a score between 0 and 2 for women and 0 and 3 for men probable misuse for a score above 3 for women and above 4 for men probable dependence for a score above 9 in both genders in order to evaluate the participants perceptions of their relationship with alcohol two questions were added the first one explored the impression of consuming too much alcohol and the second one the impression of having difficulty controlling ones alcohol consumption these two items indirectly reflect the notion of loss of control over alcohol consumption finally as the objective of this study was to evaluate the evolution of alcohol consumption in the context of the pandemic and the lockdowns a question was asked about the evolution of alcohol consumption in this context do you have the impression that your alcohol consumption evolved with the lockdowns if so how with four possible choices increaseddecreaseddiscontinuedno change other addictive practices we explored reported consumption before during and after lockdowns the questions were all worded to focus on the evolution of consumption with the pandemic and lockdowns the use of tobacco cannabis and gambling were assessed via the questions do you smoke do you even occasionally use illicit substances if so which one with five options cannabiscocaineheroinmethamphetaminesother and do you play money and gambling games statistical analyses the data were collected and anonymized in an excel file statistical analyses were performed using r software version 353 type 1 error was set at 5 descriptive statistics were generated to describe the sociodemographic data of the sample and the relevant medical information and in particular to estimate the prevalence of alcohol use among respondents and changes in consumption in the past year univariate and multivariate logistic analyses were conducted to determine which variables were associated with increased decreased or discontinued alcohol use univariate analyses for categorical variables were performed using fishers exact test univariate analyses for quantitative variables were performed using oneway anova or a kruskalwallis test only variables that were significantly associated with a change in alcohol consumption in the univariate analyses were included in the multivariate logistic analysis a stepwise backward elimination algorithm was used to eliminate variables that provided little information in the multivariate logistic model results descriptive statistics in total 2491 subjects were included in the study the statistics for the descriptive analyses for sociodemographic variables medical and psychiatric history and other addictive practices are presented in table 1 the overall response rate in the general population could not be measured as the study was circulated online and through social media and posters in primary care settings concerning health professionals specifically at the time of the study at the university hospital of brest where the study was circulated online 4200 individuals were health professionals and 3688 were women among these health professionals 1123 responded giving a response rate of 2673 for health professionals auditc score after calculation of the auditc score 4835 of the sample was classified as having lowrisk use 5165 as having probable misuse and 088 as having probable dependence if we standardize these estimates to remove skewness towards female gender we obtain 4576 of the sample classified as having lowrisk use 5303 as having probable misuse and 121 as having probable dependence of our sample 3761 were female health professionals 741 male health professionals 372 female nonhealth professionals and 1778 male nonhealth professionals the median auditc scores were twice as high for males compared to females regardless of whether or not they were health professionals perceptions of the relationship with alcohol in our study 3152 of the participants perceived that they drank too much alcohol and 1569 perceived that they had difficulty controlling their alcohol consumption evolution of alcohol consumption of the subjects interviewed 2764 reported having increased their alcohol consumption it decreased for 147 and was discontinued for 394 and 5372 reported that they had not modified their alcohol consumption variables associated with an increase in alcohol consumption compared to stable consumption a preliminary analyses selected independent variables before reaching the final model the results of the multivariate logistic analysis for factors associated with increased alcohol consumption compared to stable consumption are presented in table 2 the likelihood to have increased alcohol use was associated with being a man p 0001 being between 45 and 65 years of age p 0001 having a family p 0 001 for those living alone versus families not being a health professional p 0039 having had a health problem during lockdown p 0001 smoking tobacco p 0001 and using cannabis p 0001 variables associated with reduced or discontinued alcohol consumption compared to stable consumption a preliminary analyses selected independent variables before reaching the final model they detail how independent variables were selected before reaching the final model since the number of respondents who ceased alcohol consumption was small they were combined with respondents who reduced their alcohol consumption the results of the multivariate logistic analysis for factors associated with decreased or discontinued alcohol consumption compared to stable consumption are presented in table 3 the likelihood to have reduced or discontinued drinking was associated with being a man p 0001 not living in the city living alone 0001 for those living alone versus families and being student and using cannabis p 0001 discussion in this general population study we obtained broad participation in the general population with 2491 responses and more particularly among health professionals with 1123 participants our population was mainly composed of women and working individuals alcohol consumption and alcohol misuse were markedly prevalent indeed 5165 of our sample presented probable misuse of alcohol this result is nearly twice as high as alcohol misuse prevalence in the general population in france 819 in addition 3152 of the participants in our study reported that they had the feeling that they were drinking too much alcohol and 1569 had the impression of having difficulty controlling their alcohol consumption concerning the evolution of alcohol consumption with the pandemic and lockdowns half of the sample reported no change but among those who reported a change the majority had increased their alcohol consumption while 147 had decreased and 394 had stopped our results on alcohol consumption contrast with those of kilian et al 17 who in their metaanalysis showed a trend towards a decrease in alcohol consumption during the first months of the covid19 pandemic in europe and with the results obtained by guignard et al in france 18 in a study conducted in israel 20 bonnynoach et al showed a positive association between the duration of the pandemic and the number of lockdowns and increased alcohol consumption we can hypothesize that alcohol consumption rebounded after the lockdowns because of a gradual return to the usual modes and places of consumption in addition to the alcohol consumption as a coping strategy to manage psychological distress it is also possible that the successive periods of lockdown opened the way to new modes of purchase and consumption and as an example sales in the united states increased by 234 at the beginning of the pandemic 2122 in contrast only 088 met the criteria for probable dependence 3 times lower than expected if we refer to the estimated prevalence of 33 of alcohol use disorders in the french population 1 this could be explained by our population profile a majority of women working this overrepresentation of women is explained by two factors women are more concerned about their health and tend to more readily participate in this type of study a onemonth alcohol abstinence campaign in europe also mobilized a majority of women and working people 23 secondly the questionnaire was widely circulated to a population of health professionals and in 2018 90 of public hospital employees in france were women 24 and in the university hospital of brest at the time of the study 875 of the health professionals were women another hypothesis concerns an underestimation by respondents of their consumption because of stigmatization which is higher in women for substance use 2526 in addition the low level of probable alcohol dependence could also be related to the selected tool auditc is a screening test but not a diagnostic test 26 27 28 we observed that people aged 45 to 65 and living with their family increased their alcohol consumption more than others in contrast being a student and being urban were associated with cessation or reduction in alcohol use decreased alcohol use among young people and students has been previously reported during lockdowns 2930 one hypothesis could be linked to changes in alcohol consumption habits reduced access to usual social drinking venues such as bars restaurants and nightclubs led to decreased drinking among young people and urban residents another hypothesis could be linked to financial restrictions since people under 25 and students had greater financial difficulties during lockdown as a result of restricted access to jobs and isolation from the family this could explain reduction or cessation of alcohol consumption people living alone were more likely to have decreased their alcohol consumption compared to those living with family social isolation is usually a risk factor for alcohol misuse but killgore et al also observed that the greatest increase in highrisk drinking over the course of the pandemic occurred predominantly among individuals confined at home close to family members 29 during the lockdowns schools and nurseries were closed and parents had to ensure that children stayed involved in educational activities while at the same time managing workfromhome responsibilities and general housework having children at home during the pandemic increased psychological distress 30 working at home was also a fundamental change workers who would never have thought of consuming alcohol at the office were now free to drink to excess during work hours these alcohol use behaviors could be responses to cope with a multifactorial anxietyridden context arising from the stresses of job loss and other economic hardships social isolation disrupted routines and the general uncertainties and anxieties concerning the virus itself this type of evolution could lead in the medium and long term to reduced motivation for work increased errors and poor judgment or absenteeism in addition the isolation and overcrowding caused by the lockdowns and working from home could have led to relationship problems all the more so if combined with alcohol consumption 31 we did not explore domestic violence in this study but piquero et al 32 showed a sharp increase in domestic violence and rodriguez et al also showed an increased risk of child abuse between before and after lockdowns 33 having had a medical or psychiatric disorder during the lockdowns was also associated with increased alcohol consumption which seems consistent with previous studies this increase could reflect alcohol consumption for anxiolytic purposes or to combat depressive affects 78 finally men and individuals with current consumption of tobacco andor cannabis tended to have increased alcohol consumption in our sample results for these people more at risk of developing alcohol use disorder pabst et al reported the greatest variations in absolute values of quantities consumed before and after lockdowns 34 people with a substance use disorder reduced or increased their alcohol consumption in units per week respectively five and eight times more than others the present study enables a focus on health professionals first the response rate was high as was the spontaneous participation of health professionals we disseminated the questionnaire through the mailing list of the university hospital and the response rate was close to a quarter of the population of professionals this reflects a real concern among health professionals for their health and addictive disorders in our study they appeared less likely to increase their alcohol consumption but other studies have reported an increase in alcohol consumption for more than 50 of medical staff during the first lockdown 35 health professionals were exposed to specific risk factors they were directly exposed to stress factors resulting from the virus and the lockdowns and they had to cope with a complete rapid reorganization of the french healthcare system consumption patterns could reflect an adaptation of healthcare professionals in the course of the pandemic as they learned to cope and work with covid19 however the composition of our sample and the diversity of the health professionals surveyed means that caution is required and more specific studies are necessary strengths and limitations one strength of our study is the sample size and diversity of the variables analyzed as well as the temporality of data collection to our knowledge few studies have examined the longerterm impact of the pandemic on alcohol consumption nevertheless the limitations of the study should also be considered the crosssectional nature of our study is a limiting factor the analyses in the study were based on data from selfadministered online questionnaires and questions about past events may have led to a recall bias the questionnaire was completed by a large sample of health professionals so that the composition of our sample was not representative of the general population indeed the sample mainly consisted of women and working individuals finally the sample was recruited in a single region of france cultural bias may exist and our results could not be generalized to the whole french population conclusions in this study we collected data on alcohol consumption in the context of a pandemic and lockdowns in a large sample in a french region the majority of the sample was constituted of working women more than half of our population responded as having probable alcohol misuse and a majority did not change alcohol consumption since the lockdowns however among those who declared a change the majority increased different variables were associated with the likelihood to have increased alcohol consumption such as being a man living with family being middle aged or having medical or addictive history on the contrary urban residents and students were more likely to reduce their alcohol consumption however these results could not be generalized and further studies are required to confirm these constatations data availability statement all data generated or analyzed during this study are included in this published article funding this research received no external funding institutional review board statement the study was conducted in accordance with the declaration of helsinki this is a descriptive observational qualitative study that does not fall under the jardé law in france the study has been submitted to a legally constituted ethics committee and deemed exempt from review informed consent statement informed consent was required from the participants in the study and obtained from all subjects involved in the study

background there is conflicting evidence on how the covid19 pandemic changed patterns of alcohol consumption while some studies have suggested that alcohol consumption decreased at the beginning of the pandemic there are limited data for a longer period the objective of this study was to investigate changes in alcohol consumption 1 year after the onset of the covid19 pandemic in france and to identify vulnerable subgroups in a french adult population methods this was a singlecenter crosssectional descriptive study selfreported changes in alcohol consumption were collected from 2491 respondents in a survey carried out in western brittany from 18 january to 9 march 2021 results of respondents 2764 reported that they had increased their alcohol consumption 147 had decreased 394 had ceased and 5372 reported no change in their alcohol consumption increased alcohol use was associated with male gender age 26 to 44 years living with a family not being a health professional having had a physical or psychological health problem during lockdowns smoking tobacco and using cannabis reduced alcohol use or cessation was associated with male gender age 18 to 25 years living in brest living alone and using cannabis conclusions our study suggests that during the covid19 pandemic a significant number of people increased their alcohol consumption in france even outside lockdowns these results should encourage health professionals and public authorities to implement more specific prevention measures to limit the risks associated with alcohol consumption

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introduction injuries due to external causes whether intentional or unintentional are one of the leading causes of death worldwide in europe injuries account for 7 of all deaths every year with traffic injuries poisonings and falls being the main causes of death related with unintentional injuries and suicides and homicides the leading causes of intentional injuries in recent decades injury mortality rates have fallen in most european countries however there are still differences between countries in mortality due to these causes in concrete people living in low and middle income countries are more likely to die from injuries than those living in high income countries these differences have been observed for all specific causes of injuries except for falls in women in addition individuals of less favourable socioeconomic positions present higher risks of dying due to the leading specific causes of death by injuries in recent years there has been an increase in the number of studies of mortality inequalities in geographical areas since area of residence has been recognised as a factor affecting health independently of individual determinants in the case of injury related mortality some studies have found that areas with worse socioeconomic indicators present higher risks of dying in particular for homicides and drug overdose in the case of suicides and traffic injuries the findings are inconclusive some studies have found associations both positive and negative in the case of suicides while others have found no association in the case of falls few studies have analysed socioeconomic inequalities for this cause at area level these studies have not found any association with socioeconomic deprivation of residence area finally it is important to note that the socioeconomic inequalities in mortality due to injuries are more pronounced among men for the majority of causes in europe socioeconomic inequalities in injury related mortality at small area level have hardly been analysed and the majority of studies have focused on comparisons between countries focus to urban population was rarely given while on one side the majority of europes population lives in cities on the other it is in the urban areas where certain external causes such as traffic injuries involving pedestrians homicides or substance abuse are more common thus the objective of the present study was to analyse socioeconomic inequalities in mortality due to the leading injury related causes of death in small areas of 15 european cities by sex at the beginning of the 21st century methods design unit of analysis and study population this was a crosssectional ecological study which forms part of the ineqcities project the units of analysis were the small areas of 15 european cities the selected cities of the study are the ones participating in this project these cities were located in a variety of regions of europe north helsinki and stockholm west london amsterdam and rotterdam zurich and brussels south turin madrid and barcelona and lisbon central east budapest kosice and bratislava and prague the study population consisted of the individuals residents in the 15 cities during a period around 20002008 information sources the majority of cities had mortality data for the years 20002008 and socioeconomic indicators for 2001 mortality data were obtained from the mortality registers of the cities or countries due to technical problems georeferencing of place of residence could not be done for several deaths in 8 cities the population data stratified by age sex and small area were obtained from census data or from the register of inhabitants for each city socioeconomic indicators were also obtained from census data in the majority of cities except in amsterdam and rotterdam which were obtained from the annual labour force survey for the years 19962008 and helsinki and stockholm which were obtained from the register for 2001 mortality and socioeconomic deprivation index the present study has analysed all deaths due to injuries international classification of diseases 10th edition icd10 v01y89 f11f16f19 and from five specific causes of death due to injuries transport injuries drug overdoses e851e855 e858 304 305 icd10 x41x44 f11f16 f19 falls suicides and homicides we included as a covariate an index of socioeconomic deprivation available for each small area of each component analysis method for instance aggregating variables expressed in different units of measurement arbitrary weights the treatment of missing values and duplicate information in addition the dp2 method allows a joint analysis of the data from all the cities in order to obtain a single index of deprivation consequently this deprivation index is comparable across all the cities studied data analysis the mortality indicator used for the analysis is the standardized mortality ratio the smr is dependent on population size since its variance is inversely proportional to the expected values thus areas with low population tend to present estimates with a high variance in order to smooth the smr we used the hierarchical bayesian model proposed by besag york and mollié this model takes two types of random effects into account spatial and heterogeneous the former takes account of the spatial structure of the data while the latter deals with nonstructural variability smoothed smr were estimated for each cause of death sex and city with the following model o i poisson log α s i h i where for each area i o i is the number of observed cases e i the expected cases θ i the relative risk with respect to the european population s i the spatial effect and h i the heterogeneous effect the expected cases in each small area were calculated by indirect standardization taking as reference the mortality rates of 25 countries of the european union for the year 2004 by sex age and cause of death these data having been provided by the world health organization the geographical distribution of the smr calculated through model 1 has been represented using maps of septiles moreover the deprivation index has also been represented as septile maps all maps were generated using the r statistical package in order to analyse the relationship between mortality and socioeconomic deprivation we fitted an ecological regression model which included the deprivation index as a covariate o i poisson log α β 1 x i s i h i where exp denotes the relative risk associated with the deprivation index in the two models an intrinsic conditional autoregressive prior distribution was assigned to the spatial effect which assumes that the expected value of each area coincides with the mean of the spatial effect of the adjacent areas and has variance of 2 s σ while the heterogeneous effect was represented using independent normal distributions with mean 0 and variance 2 h σ a halfnormal distribution with mean 0 and precision 00001 was assigned to the standard deviations s σ and h σ a normal vague prior distribution was assigned to the parameters α and β 1 relative risk estimates were obtained based on their posterior means along with the corresponding 95 credible intervals these distributions were obtained with the integrated nested laplace approximation method using the inla library of the r statistical package r2101 this method provides reliable estimates of the posterior distributions avoiding the problems and computing time that would entail resorting to monte carlo methods the analyses were performed for each city stratifying by sex in order to control for possible interactions between socioeconomic deprivation and sex due to the different impact of injury mortality in men and women finally for deaths due to homicides and drug overdose modelling was not feasible for stockholm turin madrid barcelona kosice and prague due to the small numbers of deaths in respect to the number of areas in each city results table 1 presents the number of small areas the total population and the distribution of the population by small area in each city the number of small areas varies from 17 in bratislava to 2666 in turin the median population per small area also varies by city for example the median population per area in turin was 274 inhabitants while in budapest it was 76970 inhabitants both facts indicate that the size of the small areas with available data is different in each city this table also includes a description of the deprivation index the median value of deprivation index varies from 32 in stockholm to 78 in madrid and london higher scores in the deprivation index represented higher socioeconomic deprivation table 2 presents the number of deaths by cause and sex in each city in the majority of the cities the number of deaths from all specific injury causes is higher in men with the exception of falls among men the most common cause of death is suicide in most cities except in turin where the most frequent cause are falls and in madrid lisbon and kosice where the most frequent cause of death are transport injuries among women in most cities the most common cause of death are falls except in stockholm and amsterdam where the most frequent cause are suicides and in lisbon and kosice where the most frequent cause of death are transport injuries in men helsinki and the cities of central eastern europe have the highest mortality rates from all injuries the cities of southern and central eastern europe also have the highest mortality rates from transport injuries while london and the southern cities show the lowest deaths rates from suicides in women the cities of southern and central eastern europe are characterized by the highest mortality rates from transport injuries while helsinki and western cities except london show the highest mortality rates from homicides figure 1 shows a selection of maps with different geographical patterns for mortality and deprivation in four cities of different parts of europe it shows that the spatial patterns for deprivation index and mortality due to drug overdose in helsinki and london are similar whereas the patterns for the deprivation index and mortality due to suicides in lisbon are reversed finally the pattern of mortality due to all injuries has no relationship with the deprivation index in prague table 3 presents the association between the deprivation index and injury mortality in men in general the results show that in the cities of northern and western europe there is a positive association between the deprivation index and most causes of death whereas no association is detected in the majority of central eastern european cities regarding all injury mortality there is an association significantly higher than 1 with the deprivation index in most cities table 4 presents the association between the deprivation index and injury mortality in women in general the rrs are smaller and the associations are less often significant than for men the results show that in some cities of northern and western europe there exists the most association between the deprivation index and causes of death whereas no association is detected in the majority of southern and central eastern cities regarding all injury mortality there is an association significantly higher than 1 with the deprivation index in seven cities the highest rr is obtained in stockholm in relation to specific causes of death drug overdoses and homicides are the causes presenting the strongest significant positive association with the deprivation index four cities present a significantly positive association with the deprivation index for either of these causes the highest significant rrs are found in helsinki with rr1328 95 ci 1122 to 1571 for drug overdose and rr1449 95 ci 1098 to 1887 for homicides in relation to suicide a significant positive association with deprivation index is observed in stockholm while zurich and lisbon present negative associations in the case of falls the only significantly positive association is in rotterdam and with regard to transport injuries no significant association with the deprivation index is found in any of the cities studied discussion socioeconomic inequalities in injury related mortality can be observed in the majority of the cities studied these inequalities are more pronounced in men specifically in the cities of northern and western europe socioeconomic inequalities in injury mortality are found for most of the specific causes studied these inequalities are not significant in the majority of the cities of southern europe in women and in the majority of the central eastern europe in both sexes with regard to specific causes drug overdose and homicide are the causes presenting the strongest associations with the deprivation index in both sexes in the majority of the cities the present study reveals apart from the existence of socioeconomic inequalities in injury related deaths the variations in magnitude of these inequalities between cities situated in different regions of europe although we are not aware of previous studies analyzing socioeconomic inequalities in injury related mortality in small areas within cities there are studies which have analysed differences in injury mortality between countries these studies have found that low and medium income countries have higher risks of death due to all types of injuries with the exception of falls among women compared to high income countries other studies have analysed mortality inequalities in terms of educational level for certain specific causes of injury in various european countries these studies have found association between injury mortality and low educational level the differences in magnitude of the socioeconomic inequalities found between cities may be due to various reasons on the one hand it is important to point out that the cities studied present different physical political social and cultural environments which may affect the causes and determinants of injuries thus for example in some central eastern countries of europe the strategic investments in departments of public health needed to form effective responses to epidemics of chronic disease and injury that occurred in these countries during the middle of the 1990s was minimal on the other hand the results show that socioeconomic differences seem to be greater where the injury mortality rates are lower in addition the results also show no significant associations in most cities in central eastern europe and this may be due to the lack of statistical power due to the small number of geographic areas analysed in some cities in this region of europe thus the absence of significant associations does not imply that the effect of deprivation on injury related mortality is negligible in these cities in addition the cities with small number of areas also have larger areas and therefore are more homogeneous making the detection of inequalities difficult in this sense the variations in the deprivation index between city areas in central eastern europe seem to be smaller than in other european cities the deprivation index might be a better discriminator between areas in the cities of north south and west of europe than in the central east cities and other contextual factors may be more relevant in the cities of this region second there may be differences between the cities in regard to coding of injuries in mortality registers this fact could have consequences for the reliability of the data since injuries may be underreported in the mortality registries of some cities registration of these causes is a complex procedure which combines medical and legal aspects moreover various authorities are involved in the procedures which may vary between countries for example in the cases of injury death in some countries it is not obligatory to perform an autopsy and the legal authorities decide whether a forensic autopsy is necessary this is the situation in the netherlands belgium and portugal in contrast in hungary autopsies are performed in all cases of deaths due to injury the low underreporting of injuries in hungarian mortality registers could explain why budapest is the only city of central eastern europe where socioeconomic inequalities have been detected for some causes another important aspect is the lack of communication between the person certifying the death and the legal authority in charge of the legal investigation if this investigation produces a different decision about the cause of death this information is not communicated to the certifier and the cause of death is not modified in the mortality statistics this happens in the netherlands and in spain for example in regard to the injury related mortality inequalities within a given city our results agree with previous studies which have found that areas with worse socioeconomic indicators present higher all injuries mortality risk and that the magnitudes of these inequalities are greater among men men apart from being more exposed to suffering an injury present more risky behaviours than women these behaviours increase their risk of suffering disease injury or death it could be that the expression of masculinity mentioned above is more pronounced among those of deprived areas a fact that might explain why the rr are higher among men than among women with regard to unintentional injuries we have found socioeconomic inequalities in mortality from transport injuries in some cities in men this agrees with some studies that have found that areas with worse socioeconomic indicators presented higher mortality risk related to traffic injuries more deprived areas might have poorer built environment and more infrastructure problems which can explain these inequalities however some studies conducted in cities of southern europe have not found these inequalities in addition some studies have found associations between mortality due to traffic injuries and physical and socioeconomic characteristics of the area where the injury occurred which might be different from the area of residence in the case of drug overdose some studies conducted in cities of southern europe have found that areas with greater socioeconomic deprivation present higher mortality risks for falls there are very few studies which have analysed socioeconomic inequalities in mortality for this cause at ecological level and these studies did not find socioeconomic inequalities the studies on falls often focus on children or the elderly which are the most vulnerable groups in relation to intentional injuries some studies have found that areas with greater socioeconomic deprivation present higher suicide mortality risks and this would agree with our findings among men in the majority of the cities in women we only found a positive association with the deprivation index in stockholm moreover in zurich and lisbon we found an inverse relationship with the deprivation index this divergence in direction of the association agrees with the findings of some review papers in the case of homicides some studies conducted in the united states brazil great britain and scotland have reported a positive association between homicides and area socioeconomic deprivation however it is important to note that few such studies have been conducted in european countries limitations and strengths the main limitation of this study is the comparability of the data in this regard there are considerable differences in numbers and sizes of the small areas in the different cities studied this fact can have an influence in terms of low statistical power of the data to detect significant associations especially in the cities of central eastern europe for this reason it is difficult to conclude on any substantial differences in patterns between central eastern cities and other cities moreover although the deprivation index used in the study is comparable for all of the cities it is important to note that for amsterdam and rotterdam the indicators used to elaborate the deprivation index are not based on a full population census finally in some cities it was not possible to analyse all causes due to the small numbers of deaths observed in respect to the number of areas in each city the main strength of the study is that to our knowledge it is the first project to analyse inequalities in mortality due to all injuries and to the leading injury related causes in 15 cities of different regions of europe at small area level in this sense the processes occurring in urban areas are important factors to understand the economic social political and health transformations in a country in addition these cities have different socioeconomic contexts something which provides a broad overview of the behaviour of these causes and lends consistency to the results found finally studies of small areas are less susceptible to the ecological bias component created by heterogeneity within the exposure areas or other determining factors and in addition permit detection of geographical patterns in mortality and deprivation which would not be evident with larger geographical areas conclusions this study confirms the existence of socioeconomic inequalities in injury related mortality and highlights the differences in their magnitude between various cities from different regions of europe with differing socioeconomic context studies of this type may allow identification of geographical patterns and of areas with high mortality risk and poor socioeconomic indicators which helps when developing interventions aimed at reducing such inequalities furthermore knowing that a health problem has a pattern of inequality is a first step to ensure that interventions aiming to address the problem will take these differences into account for this reason the researchers of ineqcities project have disseminated the results and have produced an atlas of inequalities in mortality in european cities which is freely available online however despite growing awareness of the existence of socioeconomic inequalities in injury related mortality not all european countries have developed policies to reduce them progress in this field requires strong political will commitments in the long term and intersectorial collaboration with priority of creating safe environments moreover the experience and knowledge generated in the different european countries may be used to identify and promote codes of good practice although to be effective interventions and programmes must be adapted to the context of each city highlights • socioeconomic inequalities exist in injury mortality at small area level in most european cities • there are differences in the magnitude of these inequalities • intersectorial collaboration is necessary to create safe environments competing interests the authors declare that they have no conflict of interest

this study analysed socioeconomic inequalities in mortality due to injuries in small areas of 15 european cities by sex at the beginning of this century a crosssectional ecological study with units of analysis being small areas within 15 european cities was conducted relative risks of injury mortality associated with the socioeconomic deprivation index were estimated using hierarchical bayesian model the number of small areas varies from 17 in bratislava to 2666 in turin the median population per small area varies by city eg turin had 274 inhabitants per area while budapest had 76970 socioeconomic inequalities in all injury mortality are observed in the majority of cities and are more pronounced in men in the cities of northern and western europe socioeconomic inequalities in injury mortality are found for most types of injuries these inequalities are not significant in the majority of cities in southern europe among women and in the majority of central eastern european cities for both sexes the results confirm the existence of socioeconomic inequalities in injury related mortality and reveal variations in their magnitude between different european cities

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background significant factors affecting disclosure of hivserostatus among hivpositive latino msm have been identified however our understanding of factors that influence disclosure of sexual orientation has lagged behind understanding factors that influence the latter is important because hivpositive latino msm who disclose their sexual orientation are also more likely to disclose their hiv status moreover disclosure of hivserostatus is associated with better health outcomes factors related to gay identification such as comfort with sexual orientation involvement in the gay community and gayrelated victimization are associated to disclosure of sexual orientation rosario schrimshaw and hunter found positive associations among comfort with sexual orientation involvement in lesbian gay bisexual and transgender related social activities and disclosure of sexual orientation among youth however experiences of gayrelated victimization can negatively impact disclosure of sexual orientation garnets herek and levy suggest that lgbt individuals who have been victimized face double disclosure being gay and a victim which can push some back into the closet while comfort with sexual orientation and involvement in the gay community may foster disclosure of sexual orientation gayrelated victimization may preclude it cultural features may also influence disclosure of sexual orientation some latino men with more hegemonic masculinity and who engage in insertive anal sex with other men may not even identify as gay making disclosure of sexual orientation irrelevant thus latino notions of masculinity may preclude disclosure of sexual orientation conversely affiliation with us culture provides a new language social context and more flexible gender norms that foster disclosure of sexual orientation characteristics of the targets of disclosure may also influence disclosure of sexual orientation for instance beals peplau and gable found that gay and lesbian individuals disclose to a female friend before than to any other target gay friends are the most frequent target of disclosure followed by heterosexual friends and family members the purpose of this study was to examine factors associated with disclosure of sexual orientation to mothers fathers and friends among hiv positive latino gay and bisexual men in addition to the five factors previously discussed time since hiv diagnosis quality of life and satisfaction with social support were included in the analyses because they also predict disclosure of hiv status a total of eight theoryinformed predictors were considered methods we recruited 300 hivpositive latino gbm in new york city washington dc and boston from hivaids services community organizations hospitals and from organizations that offered hiv testing average time hiv was 76 years to minimize researcher influence participants completed the survey on a touchscreen laptop equipped with audiocomputer assisted selfinterview technology the majority took the survey in spanish inclusion criteria were being latinohispanic 18 years or older hiv positive biologically male and gay or bisexual participants were compensated 50 for their time the george washington university irb approved the study participants mean age was 40 years range 22 to 62 years selfreported sexual orientation was 68 gay 15 bisexual 3 straight and 3 transgendertranssexual table 1 includes additional demographic information measures table 2 presents mean scale scores response options ranges and internal consistency reliabilities of measures used in final models acculturation was measured with an adapted 20item version of the abbreviated multidimensional acculturation scales the scale has two subscales which assess us and latino acculturation gender nonconformity in selfpresentation was measured with a fouritem scale of gender nonconformity to hegemonic masculinity in selfpresentation developed for the current study comfort with sexual orientation was measured having participants choose an orientation from a list then rate their comfort with it on a fivepoint likert scale gay community involvement was assessed with a sevenitem scale that included items developed for the study and items based on luhtanen and crockerss collective selfesteem scale modified for gay males gay discrimination was assessed with a sevenitem scale that includes experiences of victimization due to sexual orientation time since hiv diagnosis was calculated by subtracting date of hiv diagnosis from survey administration date quality of life was assessed with an elevenitem scale with items adapted from the hiv aidstargeted quality of life satisfaction with social support was assessed with the quality of social support scale a nineitem scale that assesses perceived support from members of the social network gender and sexual orientation of closest friend included gender of closest friend and sexual orientation of the closest male friend closest friends were classified as gay male heterosexual male or female friends disclosure of sexual orientation was assessed with two questions per target of disclosure does your know that you have sex with other men response options were yes and no participants who answered yes were asked a second question who told your you have sex with men response options i told him and someone else told him with my permission were assigned to the disclosure group no responses to the first question and all other responses to the second were assigned to the no disclosure group data analysis statistical models for each target were tested using proc glmselect set to a standard stepwise selection with entry and removal criteria set at p 15 all models contained the same variables except for the one to closest friends which also included the friends gendersexual orientation variable the resulting models were tested with multiple logistic regressions findings most participants disclosed to closest friend followed by mother and father χ 2 284 p 0001 men who disclosed to their mothers were more likely to disclose to their fathers p 0001 higher levels of us acculturation gender nonconformity to hegemonic masculinity in selfpresentation comfort with sexual orientation and satisfaction with social support were associated with disclosure of sexual orientation to mother and father greater involvement in the gay community greater satisfaction with social support and having a gay male friend were associated with disclosure to closest friend having a heterosexual male friend was negatively associated with disclosure higher levels of us acculturation were only marginally associated with more disclosure to the closest friend discussion this study investigated predictors of disclosure of sexual orientation to mother father and closest friend among hivpositive latino gay and bisexual men comfort with sexual orientation was related to disclosure to mother and father fostering comfort with sexual orientation may promote disclosure to parents but disclosure to parents may also increase comfort with sexual orientation comfort with sexual orientation however was not related to disclosure to closest friend gender nonconformity with hegemonic masculinity was associated to disclosure to mother and father it is possible that men with masculine presentation do not feel the need to disclose as readily as those with lower levels of gender conformity and therefore may need assistance disclosing to certain members of their social network higher level of us acculturation was associated to disclosure of sexual orientation to both parents and marginally associated to disclosure to closest friends acculturation to the us may assist disclosure of sexual orientation by providing new resources such as positive terms to refer to homosexuality and more flexible gender roles satisfaction with social support was also related to disclosure of sexual orientation to all three targets because communication is a twoway dialectic activity disclosing may invite provision of social support and facilitate further disclosure whereas concealment of sexual orientation may preclude others from providing support involvement in the gay community only predicted disclosure to the closest friend perhaps because this is a domainspecific factor ie other gay men are involved with the gay community but parents are not participants were more likely to disclose to gay male friends than to female friends but more to female friends than to heterosexual male friends gay male friends may be uniquely positioned to obtain and provide important health information about hiv that increases quality of life for those living with hiv and that can help prevent new infections the crosssectional design is a limitation of the study another limitation was the way questions about disclosure of sexual orientation were formulated eg intentional indirect disclosure was not considered future research using longitudinal design could further explore directionality and ascertain the order in which disclosure happened relative to variables such as satisfaction with social support mean standard deviation and αcoefficient of scale for each independent variable

individuals who disclose their sexual orientation are more likely to also disclose their hiv status disclosure of hivserostatus is associated with better health outcomes the goal of this study was to build and test comprehensive models of sexual orientation that included 8 theoryinformed predictors of disclosure to mothers fathers and closest friends in a sample of hivpositive latino gay and bisexual men us acculturation gender nonconformity to hegemonic masculinity in selfpresentation comfort with sexual orientation gay community involvement satisfaction with social support sexual orientation and gender of the closest friend emerged as significant predictors of disclosure of sexual orientation

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introduction the biological definition of aging is the accumulation of changes in the cells and tissues associated with advancing age that increase the risks for diseases and eventual death 12 an individuals biological age can differ markedly from their chronological age the extent to which they differ varies widely by individual and largely attributable to developmental and genetic defects the environment disease processes and an inherent process known as the aging process 2 this is particularly relevant to and of concern for people living with hiv the success of combination antiretroviral therapy has transformed hiv infection from a fatal to a chronic disease with life expectancy among plwh getting closer to that of the general population meanwhile these individuals present an increased prevalence of agerelated comorbidities 3 however the precise aging mechanisms among plwh vs those without hiv infection have yet to be fully understood 3 the last 15 years have seen a dramatic change in hiv epidemiology amidst improvement in treatment and care in china notably there is now a large number of plwh who are ages 50 years or older these individuals are likely to have increased odds of agingrelated noncommunicable chronic diseases and to have increased health care needs in the coming years 4 in this article we reviewed the literature on the epidemiology of aging with hiv in mainland china for this review we combed both the chineseand englishlanguage scientific literature using the broad term hiv and aging this search has resulted in a total 13 topical issues being grouped under three broad themes prevalent in the hiv and aging literature with the last two themes presented around the postulated model of the pathophysiology of aging and agingrelated comorbidities in hiv infection the themes include aging profile of the hiv epidemic prevalence and incidence of agingrelated chronic diseases and risk factors for agingrelated chronic diseases for each topical issue we first presented the latest empirical research followed by a brief summary assessment we then briefly addressed the challenges and opportunities of the next generation hiv control and prevention efforts in china aging profile of the hiv epidemic increasing survival of plwh using data from the china national hiv epidemiology and treatment databases zhang et al 5 examined the mortality rate of 145484 plwh aged 15 years or older who were eligible for cart between 1985 and 2009 they found that the overall mortality decreased from 393 per 100 personyears in 2002 to 142 per 100 py in 2009 with treatment coverage concomitantly increasing from almost zero to 634 dou et al 6 conducted a retrospective cohort study with 368449 cases on cart during 20022014 the 1 5 and 10year survival rates were 922 805 and 696 respectively among all plwh 979 898 and 810 respectively for those with baseline cd4 count 350 cellsμl another nationwide retrospective observational cohort study with 46083 hivpositive men and 22563 hivpositive women who initiated standard cart between january 1 2010 and december 31 2011 and were followed up to december 31 2015 revealed that the allcause mortality was lower in women than in men 072 95 ci 067077 p 0001 and the 4year cumulative survival was 916 for women and 863 for men 7 collectively these data demonstrate that the majority of plwh on cart in china are able to rapidly achieve virological suppression with fairly good immunological recovery which result in significant improvements in survival increasing number and proportion of newly reported older cases from 2010 to 2018 the annual number of newly reported plwh aged 60 years or older increased by 5 folds from 5946 to 31541 overall from 4751 to 24465 for older men and from 1195 to 7076 for older women respectively correspondingly the proportion of newly reported plwh aged 60 years or older increased from 927 in 2010 to 2122 in 2018 according to the statistics of chinese national center for aids and std control and prevention the majority of them were infected through heterosexual contacts and very likely owing to low knowledge of hivaids and low awareness of hiv risks among the general older population in china 8 in short the hiv epidemic has increasingly affected older people especially among older men in the past decade 10 the authors found that plwh were more likely to be frail and prefrail than hivnegative individuals this association remained significant after adjustment for potential confounders after additional adjustment for neurocognitive impairment and depressive and insomnia symptoms this association remained significant but attenuated furthermore in the plwh neurocognitive impairment depressive and insomnia symptoms were independently associated with prefrailtyfrailty these findings suggest that neurocognitive impairment and depressive andor insomnia symptoms may account for a higher prevalence of prefrailtyfrailty in chinese plwh to our knowledge this is the only published study specifically designed to investigate prevalence and correlates of prefrailty frailty among plwh in china increasing manifestation of frailty and fatigue plwh report a high prevalence rate of fatigue but none of studies have directly compared them with hivnegative individuals using data from the cnisapc wang et al 11 retrospectively examined the occurrence and risk factors of selfreported fatigue among a cohort of hiv patients in eastern china in the first 6 months after receiving cart overall 224 reported fatigue within the first 6 months after receiving cart which was negatively associated with higher education higher baseline cd4 cell count and overweight but positively associated with ≥ 50 years old at initiation of art underweight at baseline and use of efavirenz in the firstline regimen these findings suggest that initiation of cart at a high cd4 count and a healthy body mass index are assumed to experience less fatigue associated with cart than older adults and those who are underweight using a mixedmethod study design with qualitative indepth interviews with 19 hivpositive women and a quantitative crosssectional audio computerassisted selfinterviews with a convenience sample of 107 plwh in shanghai chen et al 12 noted that selfreported stress associated with living the disease sleep disturbance and fatigue were the major themes emerged from the indepth interviews and moderate fatigue severity measured with fatigue scale 13 in the crosssectional data these findings suggest that the relationship between stress and fatigue might be largely mediated through sleep disturbance prevalence and incidence of agingrelated chronic diseases cardiovascular diseases guo et al 14 retrospectively analyzed risks associated with cardiovascular diseases among 973 treatmentnaïve plwh with a mean age of 360 ± 102 years enrolled in two multicenter clinical trials the prevalence of hypertension diabetes and obesity was 84 46 and 10 respectively over 65 of the patients had at least one cvd risk factor the prevalence of 10year cvd risk ≥ 10 was 45 based upon the framingham risk score and was 33 based upon data collection on adverse events of antihiv drugs risk score 14 in another multicenter crosssectional study of 538 artnaïve plwh with a mean age of 365 ± 100 years the prevalence of hypertension and glycometabolism abnormities were 32 and 30 respectively 15 ding et al 16 examined the prevalence of hypertension among 345 plwh and 345 hivnegative individuals aged ≥ 40 years who were frequency matched on age gender and education with a mean age of 527 years where 777 were men in both groups and 87 of plwh were on cart results showed that hypertension prevalence was lower in plwh than in hivnegative participants but this association was not significant after adjusting for potential confounders among plwh older age overweight with a family history of cvds and nadir cd4 count 50 cellsμl were independently associated with hypertension collectively these findings are consistent with the global literature that plwh have higher rates of cvds diabetes mellitus in a crosssectional assessment of newly diagnosed and artnaïve plwh in 2006 from 10 provinces and municipalities 1999 had hyperglycemia 947 had impaired fasting glucose and 1052 had diabetes 18 older age lower cd4 count and minority ethnicity are associated with increased risk of diabetes in this sample ye et al 19 recently reported that the prevalence of diabetes was 114 among a total of 4376 plwh on cart with the average age of years aged 40 years or above being male hcv positive baseline body mass index ≥ 240 kgm 2 and elevated triglyceride ≥ 170 mmoll were associated with the presence of diabetes in another study cheng et al 20 reported that the prevalence of hyperglycemia was 157 among 504 aids patients who had received art for at least 3 months and was significantly associated with older age family history of diabetes overweight nadir cd4 cell counts of 50199 cellsμl and less than 50 cellsμl unfortunately little is known about the incidence of diabetes mellitus or hyperglycemia it is noted that these studies report a much higher prevalence of diabetes than those among artnaïve plwh in studies by gau et al 14 and cao et al 15 a pooled longitudinal data from a multicenter clinical trial of cart regimens between 2009 and 2010 across mainland china indicates that the incidence densities of diabetes defined as fasting glucose level ≥ 70 mmoll and ifg were 262 and 3564 per 100 py respectively and were significantly associated with advanced age and baseline fasting glucose 21 in brief the prevalence of diabetes mellitus among plwh varies significantly by the study sample geographical regions and art status kidney disease a hospitalbased multicenter crosssectional study reported that the prevalence of chronic kidney disease was 161 among 538 artnaïve plwh who tended to be older with hcv coinfection and plasma hiv1 viral load 100000 copiesml 15 another study clinically described the epidemiology outcomes and risk factors of acute kidney injury among 225 plwh who were admitted to the intensive care unit at beijing ditan hospital from june 2005 to may 2017 22 the incidences of noaki aki stage 1 aki stage 2 and aki stage 3 were 462 191 84 and 262 respectively and severe aki was an important predicator for the 60day mortality with an or of 423 22 in another study ding et al 23 retrospectively examined renal function and progression to ckd among 5533 plwh on cart between 2004 and 2016 in yunnan province of southwestern china the investigators found that progression to ckd occurred in 23 patients overall and was more frequently observed in patients with baseline estimated glomerular filtration rate 60 and 60 90 mlmin 173m 2 and older age was consistently independently associated with ckd 23 globally hivassociated nephropathy was a leading cause of hivassociated kidney diseases during the early hiv epidemic but it has largely declined in the era of viral suppressive cart 24 however plwh on treatment continue to have much higher rates of ckd than hivnegative individuals 2526 increasing their risks for cvds endstage renal disease and premature mortality 27 liver fibrosis hiv alone can induce liver fibrosis whereas coinfections with other types of hepatitis accelerate the progression of related liver diseases including liver fibrosis cirrhosis and death due to endstage liver diseases including liver cancer fortunately cart is associated with an overall reduction in liver fibrosis regardless of hbv and hcv coinfection status which mostly occurs during the first 3 months of treatment and maintains for long periods cd4 recovery and hiv rna suppression are protective factors for liver fibrosis progression nonetheless older age male hcv coinfection and tdf use are risk factors 2829 these findings suggest that early treatment can mitigate the development or progression of liver fibrosis neurocognitive impairment and disorders heaton et al 30 administered a comprehensive neuropsychological test battery to 203 hivpositive and 198 hivnegative former plasma donors in a rural area of anhui province central china using a global summary score np impairment was found in 342 of the hiv monoinfected group and 397 of the coinfected group as compared with 127 of the hivnegative controls in a second study these investigators further examined the incidence of cognitive decline over 1 year among 192 plwh and 101 demographically comparable hivnegative former plasma donors in the same area of whom 56 of hivpositive group was on cart at entry and 609 at followup the 1year cumulative incidence of cognitive decline was significantly higher among plwh than hivnegative individuals was predictable by aids status lower nadir cd4 and worse processing speed at baseline and was associated with lower current cd4 cell count and failure of viral suppression on cart at followup 31 zhao et al 32 assessed cognitive disorders in 230 hiv aids patients and 99 healthy individuals in guangxi province southwestern china with 13 tests from 12 reliable and valid neuropsychological instruments 86 patients had hivassociated neurocognitive disorders among them 42 had hivrelated neurocognitive impairment 25 had hivrelated mild neurocognitive disorder and 19 had hivassociated dementia in another study zhang et al 33 reported that 37 of 134 plwh from three different regions had hand measured by the international hiv dementia scale and np test suggesting that over onethird of plwh will develop a hand in a study of neurocognitive impairment screening using the ihds and chinese version of minimental state examination among 345 plwh and 345 hivnegative participants aged at least 40 years in zhejiang province eastern china ding et al 34 reported that plwh had higher prevalence of nci than hivnegative individuals interestingly the investigators observed significant main effects of hivand age on ihds and mmse composite scores and significant interaction effects between hiv and age on motor speed orientation registration and recall which were mainly attributed to the inferior performance of plwh aged over 60 years most recently a study of nci screening with mmse among 669 plwh and 1338 hivnegative controls frequency matched for age sex and education revealed that while 124 of plwh were detected to have nci compared with 34 of the hivnegative controls the nci prevalence was higher among women than men in the hivpositive group but not the hivnegative group 35 collectively these findings are consistent with the global literature that plwh has a higher rate of nci or neurocognitive disorders malignant tumors an early clinical epidemiological study of 3554 plwh with 11072 personyears followup from 2004 to 2008 in hubei province in central china identified 63 cancer cases with approximately 50 diagnosed with aidsdefining cancers nonhodgkins lymphoma cervical cancer and liver cancer are most common cancers in this sample 36 yang et al 37 investigated cancer morbidity and mortality among 1946 plwh in a hospital specialized in infectious diseases in beijing from 2008 to 2013 among them 77 had concurrent cancer at their first hospital admission including 336 having adcs and 664 having nonaidsdefining cancers the most prevalent nadcs were hodgkins lymphoma gastrointestinal cancer liver cancer and lung cancer patients who did not accept art were more likely to suffer from cancer and if diagnosed with cancer had lower survival rate a recent metaanalytic review 38 based on 102 articles reveals that the prevalence of major cancer risk factors is high among plwh 38 overall the summary prevalence estimate and 95 ci for each risk factor among plwh were the following 411 for current smoking 303 for current alcohol consumption 244 for overweight and obesity 125 for hepatitis b virus infection 291 for hepatitis c virus infection 339 for highrisk human papillomavirus infection from cervical samples and 786 from anal samples 27 for epsteinbarr virus immunoglobulin m positivity 947 for ebv igg positivity and 256 for ebv dna positivity 149 for human herpes virus 8 infection cancer is now one of the leading causes of death among plwh with higher incidence of both adcs and nadcs compared with the general population in many countries 3940 however research on plwh with concurrent cancer is rare in china risk factors for agingrelated chronic diseases lifestyle risk factors smoking alcohol use and obesity are common risk factors for agingrelated chronic diseases such as cvds and cancer as systematically reviewed by jin et al 38 the sprev among chinese plwh was 411 for current smoking and 303 for current alcohol drinking plwh tend to lose weight after viral infection and therefore have lower weight than normal individuals however this might be changing after cart according to jin et al the sprev for overweight or obesity was 224 among chinese plwh considerably lower than overweight or obesity rates in the general chinese population 38 ding et al 16 reported that plwh were often less overweight and obese compared with hivnegative individuals in a recently completed large crosssectional study 234 of plwh had bmi ≥ 24 kgm 2 compared with 479 among hivnegative participants whereas 489 of hivpositive group vs 478 of hivnegative group had abdominal obesity which was measured by waisttohip ratio 17 despite obesity is currently not a major current health issue among pwlh in china it is expected to increase as since 2016 china updated its art guideline and recommended initiation of art for all plwh regardless of cd4 count collectively these findings are consistent with the global literature however the scientific breadth and depth regarding the behavioral andor physical risks and hivand aging among plwh in china are scarce sleep disturbance aging and plwh often suffer from sleep disturbance and insomnia which are usually associated with frailty shorter telomere length and agingrelated ncds such as ncis 9 41• chen et al 12 initially examined sleep disturbance using general sleep disturbance scale among a convenient sample of 107 plwh the investigators found that 40 of the participants reported clinically significant sleep disturbances with an average of 3 nights of disturbed sleep in the past week in another study ren et al 42 conducted a crosssectional survey to identify prevalence and correlates of sleep quality complications using the spiegel scale with 237 plwh recruited from march to august in 2013 at hivdesignated hospitals in heilongjiang province northeastern china among them 321 were negatively affected by sleep disturbances in which nighttime dreams and waking up were the most serious complications in a third study huang et al 43 44 in brief the heterogeneity in the prevalence of sleep disturbance or insomnia reflects the variation in measurement scales and geographical regions dietary and nutrition shan et al 45 examined food intake frequency among 278 plwh who have been on art for at least 1 year in a rural prefecture of yunnan province southwestern china these investigators reported that only the average intake of cereals and beansnuts per day met the recommended quantity by the dietary guidelines for chinese residents and the average intake of vegetables aquatic products eggs milk and fruits per day was insufficient scenarios are more dire for older patients who got hiv infection through plasma donation or injection drug use and mostly coinfected with hcv at early epidemic stage in the late 1980s through 1990s since coinfection with hiv1 could alleviate iron accumulation in patients with chronic hcv infection 46 ji et al 47 implemented a communitybased planting and eating soybean project to increase soybean protein in the diet of plwh in a resourcelimited rural area in anhui province in central china participants were encouraged to eat soy food every day after harvest during the 3month intervention period 94 of the participants had eaten soy food at least 3 times a week and 96 of them ate 100 g each time after eating soy food 93 felt better 86 reported less sickness 613 had higher total blood protein and blood white protein 581 had higher blood hemoglobin and 548 had higher cd4 count unfortunately nutritional knowledge attitudes and behaviors among chinese plwh are generally deficient and need improvement for example in a crosssectional survey on 172 homosexual plwh in chongqing a metropolitan city in southwestern china the average score on the knowledge quiz was 518 eating habits did not meet the nutritional requirements and 593 did not eat breakfast every day 48 many plwh in china are living in rural areas are relatively poor and lack sufficient protein or other nutrients in their diets these studies speak to the urgent need to integrate nutrition in hiv treatment and care in china other biological and genetic risk factors hiv infection is associated with ongoing activation of the immune system and persistent inflammation despite virological suppression by cart 49 these are key driving forces in the loss of cd4 t cells progression to aids and development of nonhivrelated but agingrelated chronic complications such as cvd and certain cancers 49 50 51 an early loss of gut mucosal integrity the following microbial translocation the proinflammatory cytokine milieu and coinfections are all factors contributing to the ongoing immune activation and sustained inflammation 52 genetic factors play important roles in occurrence and development of various ncds very recently zhao et al 53 demonstrate the association between mitochondrial dna haplogroups and metabolic syndrome in plwh in china and in particular the asianspecific mtdna haplogroups g and n9 may confer higher risk for the development of mets in plwh however no studies have been reported to explore the relationship between inflammation or inflammatory biomarkers and ncds in chinese hivaids patients the role of genetic factors on hiv risks in among people of asian descent warrant additional research conclusions in this review we present a relatively comprehensive though not exhaustive coverage of hiv and aging among plwh in mainland china overall many of the agingrelated issues associated with the biological and physical aspects of living with hiv addressed here are consistent with the global literature efforts on screening prevention and management of nonhiv comorbidities are now warranted moreover due to the scant literature we did not cover macrosocial factors on hiv and aging nonetheless some of the research reviewed here do provide an opportunity to speculate what macrosocial factors might play a role in the daily lives of plwh in china we briefly address two issues pertaining to these macrosocial factors china does not have the resources to develop a comprehensive and robust system to promote the mental health among its populace in the case of plwh their mental health is often not addressed many of these individuals attribute their sleepless and fatigue to stress no doubt part of the physical conditions is due to living with the disease nonetheless the global literature unequivocally documents that depression is a common condition among many plwh 54 at the present time there is limited program addressing depression among plwh in china 55 perhaps a systematic selfmanagement intervention to decrease perceived stress could be developed and implemented in chinas resourcelimited mental health settings to reduce sleep disturbance and fatigueif not directly addressing depression as part of this dialog on the continuum addressing mental health treatment and care in china health education and promotion should occupy an important role in working with plwh for example nutrition education needs to be an integral part of the national hiv treatment and care strategies other efforts that could promote healthy lifestyles targeting plwh also need to be part of this plan these coordinated strategies are crucial to slow the stampede of the hivaging process last but not least with hiv as a chronic disease it is necessary to refocus some of the research agendas andor priorities in china aging is more than just a biological process it is also a social process for example there is an unequivocal body of global research documenting that negative macrosocial factors such poverty 56 and social isolation 5758 are contributing to a range of health disparities including living with hiv 5960 china is lacking behind other countries in the study of the effect of macrosocial determinants on the hivandaging continuum for instance we know little about how and in what way living conditions and stress induced by discrimination affect the aging process among plwh in china in brief it would be a wise investment to integrate some of the macrosocial factors into clinical andor behavioral hiv research conflict of interest the authors declare that they have no conflicts of interest human and animal rights and informed consent this article does not contain any studies with human or animal subjects performed by any of the authors publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the last 15 years have witnessed a dramatic change in hivrelated epidemiology amidst improvements in treatment and care in china with proper treatment hiv is now considered a chronic disease as a consequence many people living with hiv plwh now present agerelated comorbidities we reviewed 13 topical issues concerning the epidemiology of aging with hiv in mainland china results many of agingrelated issues associated with the biological and physical aspects of living with hiv addressed in mainland china are consistent with the global literature greater prevalence of agerelated comorbidities among plwh was observed beyond biological mechanisms associated with hiv infection and traditional risk factors other factors play a vital role in the aging process among plwh summary a stronger focus on screening prevention and management of nonhiv comorbidities among plwh is now warranted macrosocial factors need to be integrated into next generation of clinical andor behavioral hiv research to inform disease progression and management as well as prevention keywords aging hiv agerelated diseases risk factors china na he and yingying ding are cofirst authors this article is part of the topical collection on the global epidemic